Nephropathology  Specialty Conference

Case #5

The patient is a 53-year-old white male with end stage renal disease of unknown etiology.  He had been on hemodialysis for 18 months.  A glomerulonephritis was clinically suspected, however, a renal biopsy had never been performed.  In the past, the patient had been suffering from coronary artery sclerosis and was treated with coronary bypass surgery in February 1997. 

In July 1998, he received a cadaveric kidney transplant (tx).  Immunosuppression was started with a triple drug regimen (steroids, tacrolimus, azathiprine). Initially, renal function was good with s-creatinine (s-cr) levels of 130 micromoles/l) occurred and a renal biopsy was performed.  Histology revealed acute rejection (type IIA) with focal tx glomerulitis and few recent cholesterol emboli.  The rejection episode was treated with bolus steroid therapy (0.5 g for 3 days) and ATG (for 7 days).  Subsequently, the dosage of tacrolimus was increased from 2x12 mg/day to 2x18 mg/day resulting in trough levels of 14-20 ng/ml (highest level: 29 ng/ml).  Four weeks later renal function was back to baseline levels (s-cr: 140 micromoles/l).  Urine cytology at that time was unrevealing.  Two months after tx the patient developed a transient asymptomatic activation of CMV (up to 35 CMV positive cells/250.000 leukocytes) which was not treated.  Three months post tx inclusion bearing ëdecoy cellsí were noted in the urine (60 per 10 HPF) and the patient was switched from tacrolimus to CyA (2x200 mg/day with trough levels of 300-350 ng/ml).  Over the next six weeks prgressive anemia developed (lowest Hb: 6.5 g/dl; MCV:88.1 fl).  Clinically erythroaplasia was suspected and confirmed in a bone marrow biopsy revealing a decreased number of red cell precursors and scattered inclusion bearing giant cells.  The histologically suspected parvovirus infection could be confirmed by PCR in blood samples.  S-cr at time of bone marrow biopsy was 170 μmol/L.  Decoy cells were still present in the urine.  In order to treat the parvovirus infection, the patient received immunoglobulin G i.v. for three days (Sandoglobulin^TM, 36 gms per day).  Within four days, renal function deteriorated (peak s-cr: 510 micromoles/l).  Twenty-three weeks post tx a second renal biopsy was performed.

Biopsy Material

LM - 8 slides

V. Nickeleit
University of Basel
Switzerland

Click on picture to enlarge

Diagnosis: BK-virus (polyomavirus) nephropathy; Acute cellular rejection
"Osmotic nephrosis"/Acute renal failure

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