Retransplantation after post transplant lymphoproliferative disorder: overcoming the obstacles!
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CASE REPORT
Retransplantation after post transplant lymphoproliferative disorder: overcoming the obstacles! Pallavi Prasad1 · Dinesh Khullar1 · Nimish Gupta1 · Rahul Grover1 · Gagandeep Chhabra1 · Kunal Raj Gandhi1 · Sagar Gupta1,3 · Sahil Bagai1 Received: 27 August 2019 / Accepted: 24 January 2020 © Japanese Society of Nephrology 2020
Abstract Post transplant lymphoproliferative disorder (PTLD) is a rare complication after kidney transplantation. Graft dysfunction is often encountered during the course of the treatment of PTLD, at times leading to need for retransplantation. We describe here the case of a young boy who underwent retransplantation after treatment of early Epstein Barr virus (EBV) related post transplant lymphoproliferative disorder. Our case highlights the various factors needing deliberation before retransplantation including time from remission of PTLD, EBV serostatus and choice of induction and maintenance immunosuppression agents. Keywords Post transplant lymphoproliferative disorder · EBV · Retransplantation
Introduction
Case report
Post transplant lymphoproliferative disorder (PTLD), although rare, is one of the most common post transplant malignancies in kidney transplant recipients [1, 2]. Net state of immunosuppression and viral infections (especially EBV infection), are the two most important risk factors leading to development of PTLD [1]. Retransplantation after PTLD is a challenge due to the risks of immunosuppression with induction and maintenance agents on one hand and managing a potentially sensitized kidney transplant recipient on the other hand. We describe here the case of a young boy who underwent successful kidney retransplantation following treatment for post transplant lymphoproliferative disorder.
A 12-year-old boy, a case of end stage renal disease secondary to obstructive uropathy, underwent live related kidney transplantation with his mother as a donor. Induction agent used was basiliximab and maintenance agents were tacrolimus, mycophenolate sodium and prednisolone. He had an uneventful intraoperative course but developed an active T cell mediated rejection (TCMR) on post operative day three. Despite three doses of methylprednisolone, graft function continued to worsen and he was given rabbit-antithymocyte globulin (ATG), a total dose of 9 mg/kg, for steroid resistant TCMR. Graft function improved rapidly and he achieved a nadir serum creatinine of 0.9 mg/dl. He maintained stable graft function subsequently. One year later, he presented with symptoms of throat irritation and right sided ear discharge. After inadequate response with antibiotics and antihistaminics, he underwent a nasal endoscopy which revealed a friable nasopharyngeal mass. Biopsy of the mass was suggestive of a diffuse large B cell lymphoma. The large cells were CD20 positive, CD3 negative and EBV latent membrane protein 1 positive. PET scan did not show involvement of the allograft but there was involvement of inguinal lymph nodes on the right side. CSF and bone marrow biopsy were normal. Based
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