M AMER1, D NININ2, P SIZELAND1, D HENDERSON1, K RABINDRANATH1
1Regional Renal Unit, Waikato Hospital, Hamilton, New Zealand, 2Pathology Department, Waikato Hospital, Hamilton, New Zealand
Background: We report a rare case of haemorrhagic interstitial nephritis in a renal transplant recipient.
Case Report: A 72 year-old man with a deceased-donor renal transplant for four years was admitted with worsening kidney function – (creatinine 387umol/L estimated glomerular filtration rate (eGFR) 13ml/min from a baseline of 120-140umol/L, eGFR 40-50ml/min). Co-morbidities included a previous transplant rejection episode, nocardiosis, type 2 diabetes mellitus, hypertension, atrial fibrillation, gout and peripheral vascular disease. Medications were tacrolimus, prednisone, aspirin, clopidogrel, omeprazole, metoprolol, levetiracetam, co-trimoxazole, insulin, and nutritional supplements including haplophylum, flax-fibre and a multivitamin. He reported flu-like symptoms and no recent overseas travel. Examination was unremarkable except for a blood pressure of 185/91.Urine had 60×106/L red cells, 20×106/L white cells and protein 1+. Serum trough tacrolimus was 2.1ug/L (reference 5-10ug/L). He had thrombocytopenia (140×106/L), normal serum electrolytes and liver tests. CXR, ECG and transplant ultrasound were unremarkable. Despite treating his hypertension and stopping supplements, transplant function deteriorated further and a biopsy was performed. He commenced long-term haemodialysisThe biopsy showed marked haemorrhagic interstitial nephritis without granulomata, as well as multi-nucleate tubular epithelial cells with intra-nuclear viral-like inclusions. Tubular epithelium had brush-border loss and mitotic figures consistent with acute tubular necrosis. There was no evidence of rejection. Blood tests for BK virus, cytomegalovirus and leptospirosis were negative. Adenovirus staining and hantavirus polymerase chain reaction (PCR) testing on biopsy sections was negative. Electron microscopy did not contain viral inclusions.
Conclusions: Haemorrhagic interstitial nephritis is rare and seen with hantavirus, adenovirus, viral haemorrhagic fevers, leptospirosis and rickettsiosis. While normally self-limiting, immunosuppression reduction is recommended in transplant patients as it can be fatal. In our case, the aetiology remains unknown.
I am a second year renal advanced trainee, dual training with general medicine. My interests include acute kidney injury, renal physiology, peritoneal dialysis and interventional nephrology.