Acute pancreatitis associated with everolimus after kidney transplantation: a case report

Background: Acute pancreatitis (AP) following KT is a rare and often fatal complication of the early post-transplant period. Common causative factors for AP are rare after KT; anti-rejection drugs as CyA, prednisone and MMF have been implicated, although evidence is not strong and we found no reports on possible causative role for mTOR inhibitors. Case presentation: A 55-year-old Caucasian man with end-stage renal disease due to idiopathic membrano-prolipherative glomerulonephritis underwent single kidney transplantation (KT) from cadaveric donor. Anti-rejection protocol was based on Basiliximab induction followed by prednisone and mycophenolate mophetil (MMF) and Cyclosporine; Everolimus (Eve) was scheduled to substitute MMF at week 3. At day 1 he had an asymptomatic elevation of pancreatic enzymes, spontaneously resolved. The further course was unremarkable and on day 19 he started Eve, with following asymptomatic rise in pancreatic enzymes. At day 33 the patient presented with abdominal pain and a marked elevation in serum amylase (1383 U/l) and lipase (1015 U/l), normal liver enzymes and bilirubin, no hypercalcemia, mild elevation in triglycerids; RT-PCRs for Cytomegalovirus or Epstein-Barr virus were negative. The patient had no history of alcohol abuse; ultrasound, CT and MRI found no evidence of biliary lithiasis. CT scans showed a patchy fluid collection in the pancreatic head area, consistent with idiopathic necrotizing pancreatitis. The patient was treated medically and Eve was withdrawn 1 week after. Patient underwent guided drainage of the fluid collection, but developed bacterial sepsis; surgical intervention was required with debridement of necrotic tissue, lavage and drainage; immunosuppression was totally withdrawn. Following course was complicated with multiple systemic infection. Transplantectomy for acute rejection was performed, and patient entered hemodialysis. Conclusions: Our patient had a presentation that is consistent for a causative role of Eve. A predisposing condition (acute pancreatic insult during transplant surgery) spontaneously resolved, relapsed and evolved rapidly in AP after the initiation of treatment with Eve with a consistent time latency. None of the well-known common causative factors for AP was present. We discourage the use of Eve in patients with recent episodes of sub-clinical pancreatitis, since it may represent a precipitating factor or interfere with resolution

Reply to the letter of Dr Merdin

Dr Merdin kindly makes suggestions about the design of our study and asks for more information about the infectious and immunosuppressive history of our monoclonal B‐cell lymphocytosis (MBL) patients with monoclonal B‐cell lymphocytosis (MBL). In our study, we incidentally found the coexistence of five cases of MBL and monoclonal gammopathy of undetermined significance (MGUS) in a cohort of kidney transplant recipients at a median of 15 years after transplantation.1 MBL and MGUS are two pre‐malignant lymphoproliferative disorders of terminally differentiated B cells. Clinically, MBL and MGUS share common features, such as an indolent course, a late‐onset age distribution, a low rate of progression and an increased susceptibility to infections. MBL and MGUS are also the precursor states of two hematologic malignancies: chronic lymphocytic leukemia (CLL) and multiple myeloma (MM), respectively

Pressure Ulcers due to a Tunneled Central Venous Catheter in a Patient on Chronic Maintenance Hemodialysis

We describe a rare complication given by tunneled central venous catheter (CVC) in a 95-years-old woman on chronic maintenance hemodialysis (HD)

Acute demyelinating neuropathy associated with rituximab treatment in a patient with relapsing nephrotic syndrome

We encountered a 63-year-old woman who experienced acute onset of demyelinating polyneuropathy (AIDP) after rituximab infusions to treat her nephrotic syndrome (NS

Successful treatment of BK virus associated-nephropathy in a human immunodeficiency virus-positive kidney transplant recipient

BK virus (BKV) is an opportunistic pathogen in those with impaired immunity. Viral replication is generally asymptomatic but is able to induce cytopathic alterations in renal cells. If BKV infection is left untreated, it leads to BKV-associated nephropathy (BKVAN) and graft loss. There is scarce experience in the management of BKV infection in kidney transplant recipients living with HIV. We report the successful treatment of BKVAN in an HIV-positive kidney transplant recipient who experienced BKV replication in the immediate post-transplantation period. A change in therapy from calcineurin inhibitor to sirolimus, steroid withdrawal and a short course of an immunomodulatory agent (leflunomide) controlled BKV viremia in the absence of drug side-effects or impairment of graft function

Retroperitoneoscopic single site renal biopsy surgery: right indicatioBMC Urology ns for the right technique.

Bacground: Laparoendoscopic single-site surgery (LESS) has been developed in an attempt to further reduce the morbidity and scarring associated with laparoscopic surgery. In patients in whom there are indications to perform a laparoscopic renal biopsy, LESS surgery is a valid alternative to mini invasive surgery and is becoming more common. We report our experience on 14 renal biopsy procedures performed in a retroperitoneal LESS. Methods: LESS renal biopsy was performed in 14 patients 18 to 80 years old (mean age 58.3 years) during a 36 month period. All procedures were performed by a single operator. The patient was in a standard flank position. The procedure was performed using a 2.5 cm, single incision via a retroperitoneal access at the Petit ’ s triangle. A 5 mm biopsy forceps was used to collect the specimen under direct vision, and haemostasis was obtained with an Argon beam probe and the application of oxidized regenerated cellulose gauze. Results: Biopsy was performed successfully in all cases. Mean operative time was 52.64 min, blood loss was minimal, and the hospital stay ranged from 12 to 24 hours. None of the patients required narcotics or additional analgesia in the postoperative period. No postoperative complications occurred. Conclusions: The LESS technique is safe, reliable (100% success), easy to learn, and offers subjective cosmetic benefits to the patient. Minimal hospitalization requirement following retroperitoneal LESS biopsy is an additional timely advantage over laparoscopic renal biopsy. We think that with the right indications (marked obesity, failure of previous percutaneous biopsy attempts, a solitary kidney and coagulopathy) LESS renal biopsy is a good alternative to laparoscopy. Our next step will be a randomized prospective study of LESS compared with laparoscopy for renal biopsy to support our findings