Pancake kidney in a patient with chronic kidney disease: A unique presentation.

Pancake kidney is one of the least common renal fusion anomalies encountered in medical practice. Less than 30 cases of this renal variant have been reported in the medical literature. Patients are generally asymptomatic, with the diagnosis of pancake kidney usually found incidentally on imaging study or autopsy. Given the rarity of reported cases, it is difficult to establish a relationship with specific associated clinical findings. Asymptomatic patients are managed conservatively with regular follow-up. We present the case of a 69-year-old female who was found to have pancake kidney, several renal cysts, and chronic kidney disease (CKD). No other reported cases have the diagnosis of CKD.

A Rare Case of Calciphylaxis in an Orthotopic Liver Transplant Recipient with Acute Kidney Injury.

Calciphylaxis is a rare disease characterized by calcification of small- to medium-sized blood vessels in the dermis and subcutaneous fat, resulting in cutaneous necrosis. Although most commonly shown in patients with end-stage kidney disease, it has also been reported in patients with other diseases, including alcoholic cirrhosis and malignancies. Here, we report an unusual case of calciphylaxis in an orthotopic liver transplant recipient with acute kidney injury. The patient, a 43-year-old white female with a history of type 2 diabetes mellitus, alcoholic cirrhosis, and normal kidney function, presented with decompensated liver disease and hepatorenal syndrome; she no longer responded to medical treatment and required treatment with dialysis. Ten days after admission, she underwent liver transplant, resulting in improved liver function tests. She had acute tubular necrosis (creatinine peak: 325 µmol/L) from sustained hypotension during and after surgery, which required 4 sessions of dialysis over 2weeks. Six weeks after her transplant, she developed painful, nonulcerating, erythematous plaques over her shins and thighs. Skin biopsy of the lesions showed calciphylaxis, calcium deposits, and thrombotic vasculopathy. She also developed severe hypercalcemia (calcium level of 2.75 mmol/L) from immobility, which required treatment with a bisphosphonate and hemodialysis. The lesions improved 6 weeks later, and her renal function returned to normal. Calciphylaxis diagnosed in an orthotopic liver transplant recipient with acute kidney injury has not been previously reported. We hypothesize that her chronic inflammatory state caused down-regulation and low levels of fetuin A and protein C. She also had other risk factors, including hypoalbuminemia, obesity, systemic glucocorticoids, and alcoholic liver disease. Calciphylaxis can occur in patients with alcoholic cirrhosis and acute renal failure even after liver transplant. Further studies into the pathogenesis of this disease may help us understand why it develops in these patients and not others with the same risk factors.

Severe Interferon/Ribavirin-Induced Hyperuricemia and Urate Nephropathy Requiring Rasburicase and Hemodialysis in a Liver Transplant Recipient.

INTRODUCTION: Hyperuricemia caused by pegylated-interferon-α2a and ribavirin therapy has been rarely reported. We report a case of severe hyperuricemia and urate nephropathy in a liver transplant recipient with recurrent hepatitis C, which required discontinuation of therapy, rasburicase, and hemo-dialysis. CASE REPORT: A 64-year-old female liver transplant recipient was begun on treatment of fibrosis cholestatic hepatitis with pegylated-interferon-α2a and ribavirin therapy. She received a one-time dose of pegylated-interferon-α2a 135 mcg subcutaneously, and ribavirin was initiated. Within 24 hours of treatment initiation, she developed an acute kidney injury with serum creatinine increased from a baseline 132.6 µmol/L (1.5 mg/dL) to 459.7 µmol/L (5.2 mg/dL) within 72 hours. Ultrasound and computed tomography of the kidneys were normal with no stones and urinalysis showed no crystals. Her ribavirin dosage was adjusted based on her changing renal function. Within 72 hours after treatment initiation, her serum uric acid level was 1392 µmol/L (23.4 mg/dL), for which she received rasburicase 3 mg intravenously. Ribavirin was discontinued at this time. The next day, her serum uric acid level and remained elevated at 1166 µmol/L (19.6 mg/dL) and she received a second dose of rasburicase 7.5 mg and hemodialysis. Her serum uric acid level decreased to 131 µmol/L (2.2 mg/dL) and remained within normal limits; however, she continued to require intermittent hemodialysis until she died from complications of sepsis 38 days after admission. After discontinuation, she was not rechallenged with pegylated-interferon-α2a /and ribavirin. CONCLUSIONS: A liver transplant recipient with recurrent hepatitis C developed severe hyperuricemia and urate nephropathy shortly after receiving pegylated-interferon-α2a and ribavirin therapy. The patient's hyperuricemia was managed with rasbu-ricase and hemodialysis. This rare but potentially serious adverse reaction can limit the use of these agents in patients with recurrence of life threatening hepatitis C after liver transplant.

Early allograft biopsies performed during delayed graft function may not be necessary under thymoglobulin induction.

OBJECTIVES: Delayed graft function affects up to 50% of kidney transplant recipients. Some guidelines recommend surveillance biopsies beginning 7 days after engraftment. This may be unnecessary with anti-thymocyte globulin induction. MATERIALS AND METHODS: We conducted a retrospective study of deceased-donor renal transplant recipients with delayed graft function. RESULTS: One hundred eleven patients met the inclusion criteria. The incidence of rejections during delayed graft function was 2.7%. They were diagnosed between 9 and 11 days after transplant. The subsequent incidence of rejection at 12-month follow-up was 13.5% (n=15). The median time to rejection after transplant was 10 weeks. Fourteen of 15 patients had subtherapeutic immunosuppression. The only risk factor associated with later rejection after delayed graft function was use of donors after cardiac death. CONCLUSIONS: Early rejection during delayed graft function with anti-thymocyte globulin induction and maintenance immunosuppression with tacrolimus, mycophenolate mofetil, and steroids is rare. When later rejection occurs, it is at a median of 10 weeks after a transplant. Two of the 3 early rejections were antibody mediated. Later rejections were associated with subtherapeutic immunosuppression and donors after cardiac death. Biopsies need not be performed during the early postoperative period when anti-thymocyte globulin is used with tacrolimus, mycophenolate mofetil, and steroids.

Horseshoe kidneys: an underutilized resource in kidney transplant.

OBJECTIVES: Although the number of patients awaiting renal transplant is rapidly increasing, the donor pool has remained relatively stable. Horseshoe kidneys, a common renal fusion anomaly, can provide a useful solution to the ever increasing gap between supply and demand. MATERIALS AND METHODS: These kidneys can be transplanted, en bloc, into a single recipient or divided and transplanted into 2 recipients. RESULTS: We report 2 cases of successful kidney transplants. CONCLUSIONS: The first is a split horseshoe kidney, transplanted into a single recipient, and the second, a horseshoe kidney from a donor after cardiac death split and transplanted into a single recipient. The second case is the first reported case of a horseshoe kidney transplant from a donor after cardiac death. We also performed a review of the literature of horseshoe kidneys with the hope of raising awareness of the necessity and promise of such transplants.

Cutaneous metastasis of pancreatic adenocarcinoma after kidney transplant: a case report and review of the literature.

OBJECTIVES: Pancreatic cancer is one of the most lethal human cancers. Each year in the United States, about 42 470 individuals are diagnosed with this condition, and 35 240 die, despite advances in imaging, medical treatment, and surgical intervention. Often, 80% to 90% of pancreatic cancers are diagnosed at the locally advanced or metastatic stage. However, cutaneous metastases originating from pancreatic cancer are rare. If cutaneous metastases do indeed occur, it is often near the umbilicus, known as the Sister Mary Joseph's nodule. Nonumblical cutaneous metastases are rare, with only several cases reported, but none regarding lesions after organ transplant. We introduce the first reported case of a cutaneous metastatic lesion of pancreatic adenocarcinoma after the transplant of an organ. We also performed a literature review and an analysis of reported cases of nonumblical cutaneous metastases of pancreatic adenocarcinoma. MATERIALS AND METHODS: We performed a MEDLINE and PubMed search of reported nonumblical cutaneous metastases of pancreatic adenocarcinoma since 1980 after a literature review and analysis. RESULTS: Our case involved a 76-year-old woman who developed cutaneous pancreatic adenocarcinoma metastases in her surgical wound 2 years after a bilateral kidney transplant. This is the first case of pancreatic adenocarcinoma cutaneous metastases after an organ transplant. CONCLUSIONS: The death rate from cancer has increased as the population has aged. This also holds true for transplant recipients. Some believe that cancer will soon surpass cardiovascular disease as the major cause of mortality after transplant. Therefore, it is incumbent upon us to appropriately screen patients with age-appropriate evidence-based examinations. Additionally, those patients with suspicious presentations should be judiciously evaluated to discover a cure for cancer as quickly as possible.

Nephrolithiasis as primary symptom in sarcoidosis.

A 30-year-old black woman presented with a 1-year history of repeated episodes of worsening weight loss and fatigue. Physical examination showed no skin lesions and a chest roentgenogram was normal. Workup showed no obvious cause of recurrent renal stones. Finally, the detection of lymphadenopathy led to the diagnosis of extrapulmonary sarcoidosis. Up to 4% of all cases of sarcoidosis may present with urolithiasis only. Renal stones may be more common in severe cases of sarcoidosis, which affect blacks most frequently. Although not generally recommended for diagnostic purposes in sarcoidosis, in this case determination of the angiotensin-converting enzyme level was helpful in making the correct diagnosis. It is important that physicians are aware of the possibility that sarcoidosis may present as urolithiasis, even in the presence of a negative chest roentgenogram.