Interesting pulmonary case scenarios in renaltransplant patients NIMS.

Case 1 31/M hypertensive, nondiabetic Native kidney disease- CGN-CKD Date of transplant- jan 2016 Donor- sister,35/f HLA&LCM- haplomatch,negative Induction- not given Maintenance therapy- wysolone,tacrolimus,MMF

. Immediate &normal graft function Current immunosuppression- T.wysolone 12.5mg,tacrolimus 1mg – 2mg, T.MMF750 mg BD. Presented to OPD on 27/8/16 with complaints of exertional SOB .

. pt admitted and evaluated.cardiac evaluation normal.EF- 65%.MILD PAH. ECG- LVH CXRPAView- normal ABG- ph- 7.35 po2- 88, spo2- 98 HCO3- 22 Hb- 12

. As pt SOB decreased and no obvious abnormality detected,he got discharged next day. 3 days later pt again came with c/o exertional sob which increased in intensity over 2 days. No pnd/orthopnea/wheeze/chestpain

. o/e- tachypnea,tachycardia present. lungs –clear spo2- 97% on room air ABG- PH- 7.36 PO2- 60 HRCT CHEST was done which showed diffuse ground glass opacities bilaterally.

. Provisional diagnosis of PCP was made and pt stareted on cotrimoxazole therapy.he was also treated with empirical iv antibiotics. On day2,in view of tachypnea and decreasing po2 pt was electively intubated,sedated and paralyzed.bronchoscopy was done and BAL sent for analysis.

. Cytology- 50.N60,L40 Grams,AFB,KOH,Galactomannan,culture – neg Xene-expert- neg Iv cotrimoxazole continued.but,pt has persistant hypoxemia,developed hypotension,renaldysfunction.progressively desaturated despite of ventilatory support and got cardiac arrest on day3 and expired.

Postmortem biopsy done which showed

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Case 2 23 yr female nondiabetic, nonhypertensive Native kidney disease- ?CGN-CKD Date of transplant-18-02-2016 Donor- brother,27/m HLA & LCM- haplomatch,negative Induction therapy – not given Maintenance therapy- wysolone.tacrolimus,MMF

. Immediate graft function No peripoperative complications. Normal stable graft function till date. Present immunosuppression- t.wysolone 12.5mg,tacrolimus 1.5mg BD, MMF 1-750 Pt presented to us with chief c/o ExertionalSOBfromweek.nopnd/orthopnea/wheeze/chestpain/palpitation No h/o fever/cough/cold/appetite loss/wt.loss

. Pt evaluated and found to have CBP – Hb%-10.9 TLC- 15000 plateletcount-2.3 ESR- 35 CUE - normal

. ECG – Normal 2D echo – good biventricular function EF- 69% ABG – ph – 7.48 po2- 83 pco2- 38 HCO3- 22.2 PFT-not able to do

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. Bronchoscopy BAL – cytology- 40. 100% lymphocytes grams stain- neg AFB stain- neg KOH stain- neg galactomannan-neg xene expert- neg culture - sterile

. Mantaux – negative.CMV PCR- neg In view of pt symptomatic and presence of hypoxemia and diffuse ground glass opacities on HRCT chest ,provisional diagnosis of pjp pneumonia was made and pt started on iv cotrimoxazole according to eGFR. As pt has no improvement, on day 6 repeat HRCT chest was done

. Radiologist and pulmonologist opinioned as drug induced hypersensitivity pneumonitis. Review of literature showed case reports of tacrolimus related lung injury. Dose of tacrolimus decreased.pt was given pulses of low dose steroids for 3 days to prevent development of chronicity.

. To confirm the diagnosis, transbronchial lung biopsy was done which showed pneumocystis

PAS stain

Sm stain

. Inj.cotrimoxazole continued for 3 weeks. Dose of MMF also decreased. Pt now is asymptomatic.pt now is on t.tacrolimus 1mg BD,MMF 750mg BD, t,wysolone 20mg od.

Case 3 52/m live related renal transplant in 2009 with mother as donor. initially on cyclosporine,azuron,wysolone in dec 2015, biopsy proven AMR.initiated on tacrolimus,MMF,wysolone. Symptomatic from 10 days with fever,cough,exertional sob

..

PAS STAIN

S.M STAIN

. Bronchial washings cytology showed PCP positive. CMV PCR- Positive. Pt treated with cotrimoxazole.valgancyclovir.pt improved symptomatically.

discussion In more recent studies, SOT recipients represent ~30% of HIV-negative immunocompromised patients. PJP is an opportunistic fungal infection .Cases are mainly in kidney-transplant recipients because this is the main type of transplantation. it occurs in 6% of RTRs if no prophylaxis is given to them.  Gerrard JG. Pneumocystis carinii pneumonia in HIV-negative immunocompromised adults. Med J Aust.1995;162:233–5.

. The risk factors for PJP in RTRs are the number and type of acute rejections, cytomegalovirus infection, other immunomodulating co-infections such as tuberculosis, hepatitis C and the use of potent immunosuppressive agents. Radisic M, Lattes R, Chapman JF, del Carmen Rial M, Guardia O, Seu F, et al. Risk factors for Pneumocystis carinii pneumonia in kidney transplant recipients: A case-control study. Transpl Infect Dis. 2003;5:84–93.

diagnosis

CXRPA view HRCT –CHEST- sensitivity 100% and specificity 89%.

prophylaxsis Current European Best Practice Guidelines recommend at least 4 months of PJP prophylaxis post-renal transplantation. KDIGO guidelines suggest 3–6 months . Both guidelines advocate additional prophylaxis during and following the treatment of acute rejection. the American Society of Transplantation Guidelines recommended 6–12 months

Take home message PCP can present as ILD. Simple exertional sob Coinfections need to be ruled out. cotrimoxazole prophylaxsis?

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