1. + Case Study One Pediatric Patient’s Experience Shelley Chapman RN, BSN, CCTC Children’s Hospital of Wisconsin

2. + Patient History 15 year old Caucasian male Past medical history Liver transplant 3 year old Fulminant liver failure of unknown etiology Bone marrow transplant 12 years old Aplastic anemia Kidney transplant 13 years old Immunosuppression

3. + Patient Presentation Presented to the Renal Clinic 5 day history of dysuria 2 day history of gross hematuria Labs Creatinine elevated at 1.49mg/dl Increased from his baseline of 0.8mg/dl Hospital admission Further evaluation and presumed rejection Renal ultrasound was done to evaluate for stones IV fluids on the day of admission

4. + Patient Presentation: The Next 48 Hours Peaked at 5.13mg/dl Creatinine Biopsy scheduled Dose of Methylprednisolone given No rejection or signs of acute interstitial nephritis Kidney Biopsy Biopsy Blood Viral Studies

5. + Patient Presentation Cont. Viral StudiesAdenovirus POSITIVE 50,000 copies PCR ID and BMT Consult CMV EBV BK Negative

6. + Treatment Recommended treatment for Adenovirus s/p BMT Cidofovir and Probenecid Side effect is nephrotoxicity Alternate prodrug formulation of Cidofovir (CMX001) recommended Drug currently in clinical trials

7. + Treatment Continued The Adenovirus PCR peaked at 137,000 copies Slowly improved Experienced intermittent fevers without bacteremia Immunosuppression changes DC Mycophenolate Mofetil Continued on Tacrolimus and Prednisone Patient discharged to home after 10 days

8. + Outpatient Treatment & Follow-up Administered medication 2 times per week in BMT clinic Treatment for 13 weeks CMX001 Outpatient Treatment Significant diarrhea Required home IV fluids Liver function studies and other labs stable Treatment Side Effects Urine adenovirus positive Blood adenovirus negative after 5 weeks Creatinine returned to baseline 0.9mg/dl Treatment Outcome

9. + 1 Year Follow-up Creatinine 0.9mg/dl No hematuria or dysuria Adenovirus negative

10. + Lessons Learned Do not assume patient is having rejection with sudden and substantial decline in renal function

11. + Discussion and Questions