Post-Transplantation Lymphoproliferative Disorder in the Renal Transplant Ureter

Abstract

A 62-year-old white man with renal failure secondary to polycystic kidney disease received a cadaveric kidney from a 2 DR-matched, 14-year-old boy by end-to-side vascular and Lich ureteroneocystostomy anastomotic techniques in February 1993. Immunosuppression was induced intravenously with 3 mg.kg. cyclosporine, and corticosteroids tapering from 500 to 30 mg. by day 7. Because the donor tested positive for cytomegalovirus and Epstein-Barr virus, the recipient was treated with 200 mg. acyclovir orally 4 times daily for 3 months for prophylaxis. Only the Epstein-Bam virus IgG titer was positive (1:640) in the recipient. After a convalescence free of rejection episodes or clinical infections the recipient presented 3 months postoperatively with serum creatinine increased to 4.9 mg./dl. from a nadir of 1.5 mg./dl. (normal 0.5 to 1.4) in the absence of lymphadenopathy, organomegaly, fever, night sweats or weight loss, and while receiving 20 mg. prednisone and 7 mg./kg. cyclosporine daily. Cyclosporine trough levels measured by selective antibody fluorescence polarization immunoassay ranged from 300 to 400 ng./ml. Ultrasound showed hydronephrosis and an antegrade nephrostogram demonstrated distal ureteral stenosis (fig. 1). Percutaneous renal biopsy revealed borderline acute cellular rejection (Banff classification). End-to-side ureteroureterostomy was performed. Histopathological evaluation showed atypical B-cell lymphocytes (nonHodgkin's lymphoma) in the resected 4 cm. distal ureteral segment (fig. 2). Serum electrophoresis revealed a monoclonal IgG kappa protein spike. Polymerase chain reactions demonstrated rearrangement of the immunoglobulin heavy chain genes. In situ deoxyribonucleic acid hybridization showed Epstein-Barr virus. Bone marrow biopsy, chest x-ray, and abdominal, pelvic and brain computerized tomography were negative. Cyclosporine was decreased to 5 mg./ kg. daily and prednisone was decreased to 10 mg. daily. At discharge home serum creatinine was 2.2 mg./dl. At 19 months serial computerized tomography is negative and serum creatinine is 2.9 mg./dl. In conclusion, in contrast to 2 previously reported cases of polyclonal lymphoma of a transplanted ureter2 and lymphoma in the renal h i l ~ r n , ~ our case represents a monoclonal neoplasm.