First documented case of BK nephropathy in kidney transplant recipient in Croatia: usage of urine cytology in evaluation process [Prvi potvrđeni slučaj BK virusne nefropatije u bolesnika sa transplantiranim bubregom u Hrvatskoj: korištenje citološke analize urina u otkrivanju bolesti]

Kovačević Vojtušek, Ivana and Gracin, Sonja and Knotek, Mladen and Ljubanović, Danica and Kardum-Skelin, Ika and Sabljar Matovinović, Mirjana (2010) First documented case of BK nephropathy in kidney transplant recipient in Croatia: usage of urine cytology in evaluation process [Prvi potvrđeni slučaj BK virusne nefropatije u bolesnika sa transplantiranim bubregom u Hrvatskoj: korištenje citološke analize urina u otkrivanju bolesti]. Collegium Antropologicum, 34 (1). pp. 255-259. ISSN 0350-6134

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Abstract

BK virus associated nephropathy (BKVAN) in transplanted kidney, although recognized as a distinct entity in the 1970-es, continues to represent a challenge in kidney transplantation, mainly because the optimal treatment approach has not been determined yet. The fact that about 10–20% of patients have simultaneously some stage of acute rejection, complicate the treatment even more. Herein we present a case of BK nephropathy in the patient, one year after combined liver and kidney transplantation, complicated by episode of acute T-cell mediated rejection. Identification of decoy cells by cytology urine exam in patient with acute kidney graft function deterioration, raised suspicion of BKVAN. Diagnosis has been made by histological examination and confirmed with immunohistochemical staining for BK virus in kidney graft biopsy. One month after he had been treated for BKVAN with intravenous immunoglobulin, leflunomide and overall immunosuppression therapy reduction, there was further deterioration of graft function due to an episode of acute T-cell mediated rejection (Banff classification IA). He received 500 mg of metilprednisolon intravenously and mycophenolate mofetil had been reintroduced, which resulted in slow partial recovery of the graft function, but never to the baseline values. For the past two years his renal graft function has been stable, maintaining lower levels of immunosupressive therapy. According to our knowledge this is the first documented case of BK virus associated nephropathy, diagnosed and confirmed with immunohistochemical staining of tissue from kidney biopsy in Croatia.

Abstract in Croatian

BK virusna nefropatija, koja je prepoznata kao posebni entitet u transplantiranom bubregu još tijekom 1970-tih godina, i dalje predstavlja dijagnostički i terapijski izazov u transplantacijskoj medicine. Otprilike 10–20% bolesnika istovremeno razvije određeni stupanj akutnog odbacivanja grafta bubrega, što dodatno komplicira pristup liječenju. Prikazujemo slučaj nefropatije uzrokovane BK virusom u bolesnika, godinu dana nakon istovremene transplantacije bubrega i jetre, čije liječenje je dodatno komplicirala epizoda akutnog odbacivanja bubrega. Temeljem citološke analize i nalaza tzv. »decoy« stanica u urinu bolesnika sa akutnim pogoršanjem funkcije grafta bubrega, postavljena je sumnja na BK virusnu nefropatiju, a dijagnoza je postavljena temeljem patohistološke analize bioptata tkiva bubrega i specifičnog imunohistokemijskog bojenja tkiva na BK virus. Bolesnika smo liječili smanjenjem ukupne doze imunosupresivne terapije, uz adjuvantnu intravensku primjenu humanog imunoglobulina, te zamjenom mikofenolat mofetila sa leflunomidom. Mjesec dana nakon početka liječenja dolazi do daljnjeg pogoršanja bubrežne funkcije, uzrokovane patohistološki dokazanom epizodom akutnog odbacivanja posredovanog T-limfocitima. Bolesnik je liječen parenteralno Solumedrolom, uz ponovo uvođenje mikofenolat mofetila, čime se funkcija grafta bubrega djelomično oporavlja i ostaje stabilna tijekom posljednje dvije godine, uz trajno nižu razinu ukupne imunosupresivne terapije. Temeljem našeg saznanja, radi se o prvom potvrđenom slučaju BK nefropatije u bolesnika s transplantiranim bubregom u Hrvatskoj, čija je dijagnoza postavljena temeljem specifičnog imunohistokemijskog bojenja tkiva bubrega na BK virus.

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