Late Allograft Renal Vein Thrombosis Treated With Anticoagulation Alone: A Case Report.

BACKGROUND: Allograft renal vein thrombosis is a rare complication of kidney transplantation. Most cases occur in the first 2 weeks after transplantation, but there are cases described many years after the transplant surgery. Allograft loss is the usual outcome. METHODS: We present a case of a renal transplant recipient with allograft renal vein thrombosis associated with deep venous thrombosis of a lower limb, 9 years after transplantation. He was successfully treated with anticoagulation alone, with recovery of allograft function. RESULTS: The patient was given unfractioned heparin and elastic compression stockings. Five days later, the patient recovered diuresis and hemodialysis treatment was discontinued. Doppler ultrasound was done and revealed partial re-permeabilization of allograft renal vein, with maximal velocity of 15 cm/s. After 30 months of follow-up, the patient was maintained on oral anticoagulation with warfarin, and no thromboembolic or hemorrhagic events were documented. The patient's serum creatinine was stable, between 1.6 and 1.8 mg/dL. CONCLUSIONS: Our patient demonstrated that anticoagulation alone and dialytic support might be able to promote total recovery of allograft function after renal vein thrombosis.

Cryptococcosis in Renal Transplant Recipients: A Single-Center Experience.

BACKGROUND: In solid organ transplant patients, 8% of invasive fungal infections are attributed to Cryptococcus. The aim of this study was to determine the frequency, risk factors, clinical characteristics, and outcome of kidney transplant recipients (TR) infected with Cryptococcus. CASE SERIES: Between 2007 and 2014, a total of 500 kidney transplantations were performed at São João Hospital, in Porto, Portugal. Six infections by C. neoformans were reported, an incidence of 1.2% (3 disseminated, 2 meningeal, and 1 cutaneous). Patients were 65-72 years of age and 4 of 6 were male, compared with all kidney TR, among whom the mean age was 51.1 years and 60% were male. Three cases of crytococcosis occurred within the first 6 months after transplantation; 3 patients had cytomegalovirus infection and leukopenia, and 2 patients' immunosuppression had been increased in the last 6 months. Meningitis presented with headache, fever, and acute mental confusion; pulmonary involvement presented with respiratory insufficiency and infiltrative or nodular lung lesions; and cutaneous infections presented as cellulitis or skin abscess. Blood cultures for C. neoformans were positive in 3 cases; all of these patients had positive cryptococcal antigen of 1:128 to 1:8192. Five patients received liposomal amphotericin B for 9-21 days, followed by fluconazole. Four patients lost their grafts, and one patients died after a persistent vegetative state due to cryptococcal meningitis. CONCLUSIONS: This small case series led to suspicion of an association between cryptococcosis and older age, renal dysfunction, cytomegalovirus infection, and intensification of immunosuppression after rejection episodes. In our series, cryptococcosis was associated with poor graft outcome.

Post-transplant Lymphoproliferative Disorder: A Single-Center Experience.

BACKGROUND: Post-transplant lymphoproliferative disorder (PTLD) is the second most common neoplasia after adult kidney transplantation (KT). METHODS: We retrospectively analyzed 8 adult patients who underwent KT in our center, diagnosed with PTLD between 2001 and 2014. RESULTS: Six patients were men. The median age at presentation was 43 years and the median time since transplantation was 7.3 years. Three patients had previously received anti-thymocyte globulin/OKT3, and all were taking calcineurin inhibitors (CNI) at diagnosis. The monomorphic type was the most common, with diffuse large B-cell lymphoma as the origin. The most frequent presentation was fever. Four in five patients had Epstein-Barr-related PTLD. All patients received various regimens of immunosuppression reduction (IR), with 4 converting CNI to mTOR inhibitor (imTOR). Subsequent treatment (when needed) was chemotherapy, radiotherapy, and surgery. The maximum follow-up time was 6.7 years, with a 50% mortality rate that occurred at a median time of 3.5 months (2 died with functioning kidney). All 4 patients who were in remission at the end of follow-up had CNI conversion to imTOR, and none lost the allograft. CONCLUSIONS: Despite the small number of cases, our results confirm the high PTLD impact in overall and allograft survival. Our PTLD type distribution is in accord with the literature. First-line PTLD treatment is IR, but the best method is still unknown; our results may suggest a beneficial effect of CNI conversion to imTOR.

Bacteremia due to Campylobacter in renal transplantation: a case report and review of literature.

Campylobacter species are the leading cause of acute bacterial diarrhea in industrialized countries. However, bacteremia is detected in <1% of patients with Campylobacter enteritis and is most likely to occur in patients who are immunocompromised or of older age. To our knowledge, only 2 cases of Campylobacter jejuni bacteremia have been reported in renal transplant recipients (RTRs). We present a case of an RTR with C. jejuni bacteremia presenting as self-limiting diarrhea followed by fever and cellulitis. The patient was successfully treated with a 2-week course of imipenem and developed no other complications. We review all cases of Campylobacter bacteremia in RTRs, and discuss clinical presentation and treatment of this potentially fatal disease.

Renal transplantation in human immunodeficiency virus-positive patients: a report of four cases.

INTRODUCTION: Renal transplantation (RT) in patients infected with human immunodeficiency virus (HIV) has significantly improved under the advent of combined antiretroviral therapy (cART). The authors describe their experience in RT in patients with HIV from September 2010 to June 2013. CASES REPORT: Four patients underwent transplantation (3 with HIV-1 and 1 with HIV-2), three patients were male, and one was black. None were coinfected with hepatitis B virus (HBV) or hepatitis C virus (HCV). Etiology of kidney disease was HIV-associated nephropathy (2 patients), immunoglobulin (Ig)A nephropathy, and unknown. Average age at RT was 51 (range, 41-63) years. No patient was of high immunologic risk. Immunosuppression consisted of basiliximab for induction and prednisolone, tacrolimus (TAC), and mycophenolate mofetil for maintenance. TAC levels varied considerably in the early days (8.5-46 ng/mL), requiring major adjustments in TAC dose. Only the HIV-2 patient had delayed graft function. The follow-up of patients with HIV-1 was 37, 19, and 16 months, and 3 months for the HIV-2 patient. CD4+ T cells decreased in the early days after transplantation with subsequent improvement, along with persistent virological suppression. In the HIV-1 group there were no major infectious, cardiovascular, or neoplastic complications. Nevertheless, the HIV-2 patient died 3 months after RT due to H1N1 pneumonia complicated by pulmonary aspergillosis. Average estimated (CKD- EPI) glomerular filtration rate (eGFR) at 6 months was 85.6 mL/min/1.73 m(2). CONCLUSION: Besides the difficulty in adjusting calcineurin inhibitors levels due to its interaction with antiretroviral therapy, namely with protease inhibitors, no patient had acute rejection. Furthermore, all patients presented an excellent control of viro-immunologic parameters. At the last follow-up neither cardiovascular events nor neoplastic complications were observed. Our results highlight the favorable outcome of RT in HIV-1-infected patients. The HIV-2 patient died due to severe infection, and the clinical management and potential benefit of RT in HIV-2-infected patients needs further study.

Early-onset of disseminated cryptococcal infection in two renal transplant recipients.

Cryptococcosis is the third most common invasive fungal infection in organ transplant recipients after candidiasis and aspergillosis. Newly acquired and reactivation of latent infection are the major causes of infection, with typical later-onset and mainly as disseminated infection. The type and intensity of immunosuppression, diabetes mellitus and other co-morbidities as well as uremia seem to be important determinants on clinical presentation and outcome. Moreover, the diagnosis is not always apparent since it usually presents subacutely, as well as mimicking bacterial infections, which may be responsible for a delay in the diagnosis. Thus, a high degree of suspicion and need of invasive procedures for microbiological and histological evaluation are critical for definitive diagnosis and prompt institution of adequate treatment. We report two cases of disseminated cryptococcosis with different presentations and with an early-onset after renal transplantation.

Cerebral coccidioidomycosis after renal transplantation in a non-endemic area.

Coccidioidomycosis is a fungal infection caused by Coccidioides species endemic to the desert south western United States. In healthy people, manifestations range mainly from asymptomatic to mild influenza-like syndrome. In immunosuppressed patients, extrapulmonary dissemination is common. We report the case of a patient with a parenchymal central nervous system lesion. This presentation is considered very rare. The highest risk of infection after solid organ transplantation occurs during the first year. Risk factors include treatment of acute rejection. In the reported case, the infection was probably donor-derived, as our patient had no history of traveling to endemic areas. Mortality is high among transplanted recipients with coccidioidomycosis, particularly those with disseminated infection.