SUN-332 POST TRANSPLANT GRAFT ABSCESS IN HEPATITIS-B POSITIVE RECIPIENT

Abstract

Graft-site candidiasis is a rare manifestation of invasive fungal infections, with a risk of 1.3% in kidney transplants. The incidence of graft-site candidiasis is 0.1% in renal transplant recipients. Preservation of the renal graft is rarely possible when candidiasis is accompanied by vascular complications. A 24 year old male, with end-stage renal disease due to right solitary kidney with grade-3 vesicoureteric reflux, underwent left live-related donor kidney transplant with 2/6 HLA mismatch. He tested positive for Hepatitis B surface antigen, prior to continuation of maintenance hemodialysis at our center, and underwent hemodialysis for 1 year prior to transplant, hemodialysis access being left IJV cuffed hemodialysis catheter. The donor being his mother, was 45 years old, without any comorbidities. The recipient underwent right laparoscopic nephroureterectomy, on the same day, prior to transplantation. The patient received induction with Inj Grafalon, (an anti-human T-lymphocyte immunoglobulin from rabbits), intraoperatively, followed by triple-drug therapy with Tacrolimus, Prednisone, and Mycophenolate sodium. Urinary catheter, abdominal drain, left IJV cuffed hemodialysis catheter were removed prior to discharge. on day 9 he was discharged with DJ stent insitu and a baseline creatinine of 1.6 mg/dL. 19 days post transplant, he presented with facial puffiness, 4-6 loose stools, vomiting, 9 kg weight gain, oliguria and azotemia. There was no history of fever, vomiting, dysuria, bleeding manifestation, abdominal pain. He was hemodynamically stable with a hemoglobin of 7.4g%, TLC 5200/µL, Platelet 95000/ µL, serum urea and creatinine of 156 mg/dL, 6.6 mg/dL respectively. His spot UPCR was 8.3 and urine had 3+ proteinuria, 80 – 90 RBC / hpf, 15 – 20 Pus cells / hpf. His abdominal sonography was suggestive of pyelonephritis of the transplanted kidney & graft vessel doppler was normal. Urine culture was suggestive of Klebsiella pneumoniae and was treated as per antibiotic sensitivity. Due to persistent anuria, and a rising trend of serum creatinine with severe metabolic acidosis and refractory hyperkalemia, he underwent hemodialysis, via left femoral uncuffed hemodialysis catheter. DJ stent was removed. Repeat urine and blood cultures showed no growth. Stool culture also showed no growth. Repeat abdominal ultrasonography & CT-KUB were suggestive of pyonephrosis of transplanted kidney. He underwent right IJV cuffed hemodialysis catheter insertion and was put on thrice weekly maintenance hemodialysis. Post-transplant day-70, he underwent graft nephrectomy. Histopathology of multiple sections of the graft showed focal areas of abscess with non-septate fungal hyphae, numerous foreign body and langhan’s giant cells mixed with lymphohistiocytic inflammatory cells with epitheloid cells. There was evidence of tubulitis, glomerulonephritis with vessels showing hyaline arteriolar sclerosis with areas of infarcts. Sections from the ureter showed inflammatory cell infiltration of transitional epithelium and the walls showed candida, conclusive with Pyelonephritis due to candidiasis (Banff category 6). Diagnosis of fungal infection in transplant recipients can be perplex due to vague patient symptoms and lack of specificity of blood test or radiologic findings. The paucity of data regarding their management poses a challenge to transplant physicians.