COVID-19 pneumonia in a kidney transplant recipient successfully treated with tocilizumab and hydroxychloroquine

Coronavirus disease 2019 (COVID-19) pneumonia has been poorly reported in solid organ transplanted patients; prognosis is uncertain and best management unclear. We describe the case of a 61-year-old kidney transplant recipient with several comorbidities who was hospitalized and later received a diagnosis of COVID-19 pneumonia; the infection was successfully managed with the use of hydroxychloroquine and a single administration of tocilizumab, after immunosuppression reduction; the patient did not require mechanical ventilation. During the rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, transplant clinicians should be readily informed about new cases of COVID-19 pneumonia in solid organ transplant recipients, with focus on therapeutic strategies employed and their outcome.

Pathogenesis of renal injury in the megabladder mouse: a genetic model of congenital obstructive nephropathy

Congenital obstructive nephropathy (CON) is the most common cause of chronic renal failure in children often leading to end-stage renal disease. The megabladder (mgb) mouse exhibits signs of urinary tract obstruction in utero resulting in the development of hydroureteronephrosis and progressive renal failure after birth. This study examined the development of progressive renal injury in homozygous mgb mice (mgb-/-). Renal ultrasound was used to stratify the disease state of mgb-/- mice, whereas surgical rescue was performed using vesicostomy. The progression of renal injury was characterized using a series of pathogenic markers including alpha smooth muscle isoactin (α-SMA), TGF-β1, connective tissue growth factor (CTGF), E-cadherin, F4/80, Wilm's tumor (WT)-1, and paired box gene (Pax) 2. This analysis indicated that mgb-/- mice are born with pathologic changes in kidney development that progressively worsen in direct correlation with the severity of hydronephrosis. The initiation and pattern of fibrotic development observed in mgb-/- kidneys appeared distinctive from previous animal models of obstruction. These observations suggest that the mgb mouse represents a unique small animal model for the study of CON.

Medicolegal reflections about a case of cardiac death after renal transplantation

Cardiovascular disease is the most common cause of death in patients with renal transplant. Acute coronary syndrome due to coronary artery disease, and left ventricular hypertrophy leading to chronic heart failure account for the majority of sudden arrhythmic deaths after transplantation. Furthermore death with functioning graft represents the main cause of graft loss, particularly after the first post-transplantation year. Although cardiovascular disease leads to morbidity and mortality in renal transplant recipients, its pathogenesis is poorly understood. The high incidence of cardiovascular disease in patients after renal transplant is chiefly due to high occurrence and accumulation of traditional risk factors before and after transplantation. Hypertension, post-transplant diabetes mellitus and hyperlipidemia increase the risk for cardiovascular events. Also 'non traditional' risk factors are associated with cardiovascular disease. Moreover several immunosuppressive drugs interfere with the cardiovascular system. The authors present a case of cardiac death following renal transplant in a patient with history of cardiovascular disease prior transplantation. Initially treated by hemodialysis, after 3 years he received a cadaveric renal transplant. The post-transplantation period was without surgery complications, immunological or infectious, except for a scarce control of blood pressure. A month after the operation, the patient developed thrombophlebitis, plus extra-peritoneal swelling. After ten days in hospital he suddenly died. The aim of the manuscript is to remark on the legal relevance of patient's consensus to transplant. It is necessary to well inform patients of an operation's risks and complications. Furthermore, the exceeding demand with respect to organ availability raises ethical issues about organ allocation.

Rituximab therapy for Epstein-Barr virus-related chronic hepatitis following living donor kidney transplantation

A patient who underwent living donor kidney transplantation was infected with Epstein-Barr virus (EBV) that resulted in persistent EBV infection and EBV-associated chronic hepatitis, determined by abnormally elevated anti-EBV antibody titers and high frequency of EBV-infected B lymphocytes. Despite decreases in immunosuppressant doses, persistent EBV infection and chronic hepatitis persisted for several years. Therapy using anti-CD20 monoclonal antibody (rituximab) virtually eliminated peripheral B lymphocytes and EBV-encoded small RNA 1 (EBER-1)-positive cells. Moreover, hepatic enzyme levels normalized and histological findings indicated marked improvement in hepatic inflammation. Although peripheral CD20(+) B lymphocyte and EBER-1-positive cell levels began to increase 4 months after the end of therapy, the number of EBER-1-positive cells remained very low, and liver function test results remained within normal ranges. The present case illustrates the significance of early diagnosis, monitoring of viral load, and vigorous management of EBV-related disorders associated with organ transplantation.

Citrate attenuates tubulointerstitial fibrosis in 5/6 nephrectomized rats by decreasing transforming growth factor-beta1

OBJECTIVE

Tubulointerstitial fibrosis plays an essential role in progression to end stage renal disease (ESRD) in various chronic renal failure (CRF) models including the 5/6 nephrectomy (5/6). The present study examines the renoprotective effect of citrate in the renal ablative model that is quite similar to CRF in human.

MATERIAL AND METHOD

Male Wistar rats underwent 5/6 and were fed with tap water (5/6tap) or tap water containing 67 mEq/L citrate solution (5/6cit). Sham-operated rats (S) were divided into Stap and Scit groups. Renal function, renal histopathology, renal alpha-Smooth muscle actin (SMA), and renal transforming growth factor (TGF)-beta1 were determined immediately and at the 8th week after operation.

RESULTS

Following the surgery, the values of glomerular filtration rate (GFR) in the 5/6tap and the 5/6cit groups were 2.39 +/- 0.25 and 2.35 +/- 0.25 (mL/kg/min), respectively, both were significantly lower than sham groups (p < 0.05). At the eighth week, the 5/6tap group had progressively decreased GFR and had higher fibrosis score, increased alpha-SMA positive cells, and renal tissue TGF- beta1 when compared with the sham groups. The 5/ 6cit group, when compared with the 5/6tap group, had higher GFR (2.51 +/- 0.22 vs 1.17 +/- 0.33 mL/kg/min; p < 0.05), lower fibrosis score (1.83 +/- 0.88 vs 3.0 +/- 0.4, p < 0.001), lower alpha-SMA activity (159 +/- 2.9 vs 187 +/- 12.3 cells per 1000 interstitial cells, p < 0.05), and lower renal TGF-beta1 levels (1771.3 +/- 239.5 vs 4716.9 +/- 871.2 pg/mg protein, p < 0.005).

CONCLUSION

As such, in 5/6 nephrectomized rats, citrate therapy for eight weeks could decrease tubulointerstitial fibrosis mainly by reducing the heightened renal TGF-beta1 levels and additionally by attenuating the increased myofibroblast activity.

Chromophobe renal cell carcinoma in a pediatric living-related kidney transplant recipient

Renal cell carcinoma can occur in children who have received renal allografts from adults. Chromophobe renal cell carcinoma is a rare variant of renal carcinoma with distinct histochemical, ultrastructural, and genetic characteristics. We describe the incidental finding of a chromophobe renal cell carcinoma in a 13 1/2-year-old boy 5 years after receiving a living-related renal transplant. This tumor was found by serendipity during the evaluation of fever and inguinal lymphadenopathy, with the presumptive diagnosis of posttransplantation lymphoproliferative disorder. The patient was found to have cat-scratch disease. A renal cell carcinoma should be considered in the differential diagnosis of a pediatric recipient of an adult kidney with an incidental finding of a tumor in the graft.

[Hemolytic anemia caused by graft-versus-host reaction in ABO-nonidentical renal transplants from blood group O donors]

Acute hemolytic anemia is one of the side effects associated with cyclosporin and tacrolimus therapy, and three mechanisms have been described to account for hemolytic anemia in patients receiving these drugs: drug induced hemolysis, autoimmune hemolysis and alloimmune hemolysis resulting from donor lymphocytes derived from the allograft (passenger lymphocyte syndrome). We report four cases of renal transplant recipients who developed alloimmune hemolytic anemia due to minor ABO incompatibility while under treatment with cyclosporin (two) and tacrolimus (two). The anti-erythrocyte antibodies responsible for hemolysis were of the IgG isotype and showed anti-A or anti-B specificity. These findings suggest that the hemolysis could be related to alloantibodies derived from the clonal development of donor B lymphocytes in the recipients (microchimerism). In summary, hemolytic anemia due to ABO-minor incompatibility occurs infrequently after renal transplantation. Risks are higher for patients A, B or AB blood group receiving an O blood group graft under treatment with cyclosporin or tacrolimus. Follow-up of these patients is warranted for the early detection and optimal management may be achieved by reduction of immunosuppression and change to mycophenolate mofetil.

Adenine phosphoribosyltransferase deficiency and renal allograft dysfunction

Adenine phosphoribosyltransferase (APRT) deficiency is a rarely diagnosed cause of renal allograft dysfunction. We report the case of a 42-year-old man who presented in 1996 with idiopathic renal failure. Native kidney biopsy showed extensive microcrystalline interstitial nephritis. The patient subsequently underwent a living-related kidney transplant with excellent early graft function. During the next year, however, he had worsening allograft function, and allograft biopsy showed recurrent interstitial nephritis. Further chemical and spectroscopic analysis showed this lesion to be an annular microcrystalline nephritis consistent with APRT deficiency. This diagnosis was confirmed on erythrocyte assay. Treatment with allopurinol and a low-purine diet led to improvement and stabilization of renal function. APRT is a rare cause of renal allograft dysfunction requiring a high index of suspicion for early diagnosis and treatment. Increased physician awareness in the United States may hasten diagnosis and limit the morbidity associated with this disease.

[Endourological surgical techniques in interstitial nephritis]

Endourological surgical procedures (transurethral resection and fulguration, Nd-YAG-laser application) for the treatment of interstitial cystitis (IC) have been evaluated only in a few studies. Theoretically, they could be the next step in a therapeutic concept after conservative measures have failed and before open surgery is performed as an ultima ratio. However, our review of the literature suggests that to date there is no scientific evidence to support endourological techniques in the treatment of IC.

Massive T wave changes following a combined kidney and liver transplant in a young female with cirrhosis

We report the case of a young female with PSC-associated cirrhosis and chronic renal failure who developed clinical and electrocardiographic signs consistent with acute myocardial infarction after a combined kidney and liver transplant. Cardiac investigations at that time were negative and she is currently asymptomatic one year post-transplant with resolution of most of her ECG abnormalities. Although the cause of her symptoms and ECG abnormalities is not immediately apparent, this case illustrates the difficulties in interpreting abnormal cardiac investigations in transplanted patients with liver cirrhosis who may have a background of subclinical cardiac disease.

High water intake ameliorates tubulointerstitial injury in rats with subtotal nephrectomy: possible role of TGF-beta

BACKGROUND

It has been shown that tubulointerstitial injury correlates well with a decline of renal function. In this study, we investigated the effect of high water intake (HWI) on functional and structural parameters in rats with subtotal nephrectomy.

METHODS

Two weeks after the ablative procedure, rats were divided into two groups. One group received the treatment with HWI (3% sucrose added to drinking water) for eight weeks. Functional parameters were compared with sham-operated control (CONT) or nephrectomized rats without treatment (NX). Remnant kidneys were then assessed histologically for evidence of interstitial fibrosis and glomerulosclerosis.

RESULTS

Creatinine clearance was significantly improved in HWI rats compared with NX rats. Simultaneously, urinary protein was also significantly reduced in HWI rats. HWI predominantly ameliorated interstitial lesions and, to a lesser extent, glomerular lesions. Northern blot analysis demonstrated that transforming growth factor-beta (TGF-beta) mRNA expression was significantly suppressed in HWI rats. In situ hybridization revealed that HWI suppressed TGF-beta mRNA expression mainly in the outer medulla. Fibronectin mRNA was also reduced by the HWI treatment. The changes in TGF-beta and fibronectin mRNA were in parallel with Na+/myo-inositol cotransporter (SMIT) mRNA, which is regulated by extracellular osmolarity. Immunohistochemistry demonstrated that protein expression of TGF-beta and fibronectin coincided with the mRNA expression.

CONCLUSION

These results suggest that HWI reduces TGF-beta mRNA expression in medullary interstitium and ameliorates tubulointerstitial injury in rats with reduced renal mass.

Chronic cholestatic liver disease with associated tubulointerstitial nephropathy in early childhood

We report the clinical and morphological features of an unusual hepatorenal disorder in 2 patients. The main clinical features were early onset of cholestatic liver disease and progressive tubulointerstitial nephritis, leading to renal death in early childhood. Renal histology showed interstitial fibrosis, tubular atrophy and dilatation, glomerular cysts in the cortex and periglomerular fibrosis; liver histology was characterized by portal fibrosis and bile duct abnormalities. Evaluating the 12 patients published in the literature, the long-term prognosis of the liver function appears bad, suggesting the possibility of a combined liver and kidney transplantation.

Early protocol renal allograft biopsies and graft outcome

To evaluate whether biopsies performed early after transplantation in stable grafts can predict graft failure due to chronic transplant nephropathy, a protocol biopsy was performed at three months in 98 patients treated with antilymphocytic antibodies, cyclosporine and prednisone. Patients were followed for 58 +/- 16 months. Histological diagnosis according to the Banff schema were: normal (N = 41), borderline changes (N = 12), chronic transplant nephropathy (CTN; N = 30), CTN associated to borderline changes (N = 11) and acute rejection (N = 4). Biopsies displaying acute rejection were not considered for statistical analysis. Since clinical characteristics of patients displaying CTN either with or without tubulitis were not different, biopsies were grouped as presence or absence of CTN. Patients displaying CTN had an increased incidence of acute rejection before performing biopsy (24.3 vs. 3.9%, P = 0.003), a higher mean cyclosporine level until biopsy (242 +/- 74 vs. 214 +/- 59 ng/ml, P = 0.049) and a lower actuarial graft survival (80.5% vs. 94.4%, P = 0.024). We conclude that early protocol biopsies are useful to detect patients at risk of losing their graft due to chronic transplant nephropathy.

Hyperreninemia, hypertension, and congestive heart failure in focal interstitial nephritis

Hyperreninemia probably due to focal interstitial nephritis of the right kidney caused an acute onset of hypertension and cardiac dysfunction including valvular insufficiency in a 5-year-old boy. This congestive heart failure in association with valvular insufficiency and hypertension was dramatically improved following right nephrectomy. Abruptly activated renin-angiotensin II may lead to congestive heart failure and valvular dysfunction without myocardial hypertrophy in a young heart.

[Lymphoproliferative syndrome induced by Epstein-Barr virus after kidney transplantation: value of genotypic analysis]

Forty-six days after renal transplantation for inborn tubulointerstitial nephropathy, an 18-year-old man was rehospitalized for renal failure with creatinine at 200 mumol/l. There was no sign of infection and ciclosporin level was within therapeutic range. Transplant biopsy showed minor interstitial infiltration with mononucleated cells. Methylprednisolone by 10 mg/kg/d bolus did not improve renal function and OKT3 5 mg/d was substituted for ciclosporin but had to be stopped on day 8 because of a severe infectious syndrome. The patient developed fever (39 degrees C), erythemato-pultaceous pharyngitis followed by major multiple lymph node and spleen enlargement. The diagnosis of primary Epstein-Barr infection was confirmed serologically. Histology of a submaxillary lymph node reported monomorphic immunoblastic lymphoproliferation. Immunologic phenotyping showed CD19, CD20 and CD22 surface antigens characteristic of B cells and in situ Epstein-Barr hybridization was positive in 100% of the cells. Southern Blot showed an oligoclonal pattern. Ciclosporin and azathioprin were stopped and the patient was treated with corticosteroids (15 mg/d) and aciclovir given orally (3.2 g/d) for 3 months. Outcome at six months was favorable with normalization of the renal function and complete regression of the infectious syndrome. This case demonstrated the importance of molecular biology techniques for virologic and genotypic assessment of lymphomatous proliferation allowing positive aetiologic diagnosis.

[Acute tubular necrosis in patients after kidney transplantation: associated factors and impact on functional survival of the graft]

Acute tubular necrosis (ATN) represents a serious problem in kidney transplantation. We have reviewed the causes and effects of ATN on kidney transplant patients treated in our hospital between June 1981 and December 1992. We analyzed 359 consecutive kidney transplants performed in 338 patients (213 male and 125 female). There were 311 first grafts. The actuarial functional graft survival (AFGS) was 85% at 1 year and 58.2% at 10 years. The incidence of long-term chronic rejection, the 1-year creatinine blood level (CBL) and the AFGS are summarized: [table: see text] The donor age and the PRA level were significantly correlated with ATN occurrence. ATN after transplantation was associated with a poorer function and survival of the kidney graft. Better donor and patient selection could decrease the occurrence of ATN, thus improving the graft outcome.

[Cyclosporin A as a diabetogenic cofactor]

Two kidney transplanted patients are reported, who developed an insulin dependent diabetes mellitus after crossing therapeutic Cyclosporine A levels. After stabilisation of the Cyclosporine A levels the insulin dependent diabetes mellitus was completely reversible. The results are indicating Cyclosporine A as the insulin dependent diabetes mellitus initiator.

Indications of unilateral bovine nephrectomy: a report of four cases

Unilateral nephrectomy was done on 4 cows with renal disease. The history and clinical signs varied and were not pathognomonic for disease of the urinary system. Serum creatinine and BUN concentrations were normal in each cow prior to nephrectomy, in spite of advanced renal disease. Results of urinalysis were abnormal in 3 cows. Cystoscopic examination aided in the diagnosis, by revealing unilateral hematuria in 1 cow. Palpation per rectum revealed a large abdominal mass adjacent to the kidney in 2 cows. Exploratory celiotomy was necessary in 3 cows to determine the exact nature of their disease. Nephrectomy was easily performed; however, ligature security was critical. A biopsy of the remaining kidney at the time of nephrectomy aided in determining medical therapy and prognosis. Three cows recovered from the effects of the disease and became productive members of the herd. One cow was euthanatized because of end-stage renal disease in the remaining kidney.

Renal transplantation in infants and children

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