Secondary bladder amyloidosis with familial Mediterranean fever in a living donor kidney transplant recipient: a case report

[Bladder AA amyloidosis: A rare location. About a case]

INTRODUCTION

Bladder localization of AA amyloidosis is rare. It can be responsible for massive and recurrent hematuria. We report a case of bladder AA amyloidosis secondary to Crohn's disease in a renal transplant patient.

CLINICAL OBSERVATION

A 62-year-old man, suffering from Crohn's disease since 1991 complicated by renal AA amyloidosis. He received a kidney transplant since 20 years from an HLA identical donor. After an 18-year period of clinical remission, the patient was admitted for a flare-up of his Crohn's disease in the form of intermittent diarrhoea. Treatment with corticosteroids allowed a good evolution. A year later, he was rehospitalized for massive macroscopic haematuria. Histological examination of the bladder biopsy revealed AA amyloidosis. The patient fully recovered but died 6 weeks later from septic shock of urinary origin.

CONCLUSION

The treatment of bladder localization of AA amyloidosis is based on treating the cause. Hematuria is sometimes massive, exceptionally requiring emergency cystectomy for haemostasis.

Secondary bladder amyloidosis due to Crohn's disease: a case report and literature review

The presence of amyloid deposits in bladder walls is a rare histological finding. It can be linked to primary (limited to bladder) or secondary (systemic, associated with chronic inflammatory disorders) amyloidosis. Secondary bladder involvement is very uncommon; it usually presents with gross hematuria, which is challenging to manage, due to frail bladder mucosa and/or necrosis. We present a case of 54-year old man with secondary bladder amyloidosis due to Crohn's disease, that caused gross hematuria and severe anemia, which was managed conservatively by endoscopic transurethral resection, diatermocoagulation, clot evacuation and urinary drainage by bilateral percutaneous nephrostomy, with spontaneous resolution. Secondary bladder amyloidosis is a rare condition that presents with severe hematuria, difficult to control with standard management. Owing to chronic nature of the disease, treatment should be aimed to a conservative approach whenever possible. In case of failure, invasive procedures should be considered as salvage therapies.

Living kidney transplantation between brothers with unrecognized renal amyloidosis as the first manifestation of familial Mediterranean fever: a case report

BACKGROUND

Familial Mediterranean fever is an autosomal recessive disease characterized by recurrent episodes of fever and polyserositis and by the onset of reactive amyloid-associated amyloidosis. Amyloidosis due to familial Mediterranean fever can lead to end-stage renal disease, culminating in kidney transplantation for some patients. In this study, we report the clinical outcome of two brothers with familial Mediterranean fever who were the inadvertent donor and recipient, respectively, of a kidney. Subsequently, they were diagnosed with renal amyloidosis secondary to familial Mediterranean fever and were successfully treated with anakinra and colchicine.

CASE PRESENTATION

Two brothers with familial Mediterranean fever and renal amyloidosis were the inadvertent donor and recipient, respectively, of a kidney. The recipient had presented recurrent acute febrile episodes of familial Mediterranean fever, developed nephrotic syndrome secondary to amyloidosis and needed bilateral nephrectomy and chronic dialysis. His elder brother, in apparent good health, donated his left kidney to his brother. Immediately after the kidney transplantation, both the donor and recipient presented massive proteinuria, impaired renal function and elevated serum amyloid A levels. Biopsies of the brothers' kidneys showed amyloidosis. Genetic studies thereafter revealed a homozygous variant for the MEFV gene (NM_000243.2.c.2082G > A; p.M694I) in both brothers. At this point, both the donor and recipient were treated with colchicine and anakinra, resulting in improved renal function, decreased proteinuria, undetectable serum amyloid A levels and stable renal function at 62 months of follow-up and no major adverse effects.

CONCLUSIONS

In familial Mediterranean fever, analyses of the MEFV gene should be performed in potential live kidney donors from a direct family member (either between siblings or between parents and children). In addition, genetic studies are required when consanguinity is suspected between members involved in the living transplant. Finally, anakinra could be a safe adjuvant therapy combined with colchicine for patients with familial Mediterranean fever and amyloidosis, including those with successful kidney transplantation.