ESPN 51th Annual Meeting

ESPN 2018


 
Leflunamide as an effective therapy in acute allograft dysfunction
TERESA PENA 1 SARA SILVA LEITE 1 LILIANA ROCHA 1 PAULA MATOS 1 SAMEIRO FARIA 1 LEONíDIO DIAS 2 CONCEIÇãO MOTA 1

1- PAEDIATRIC NEPHROLOGY SERVICE, CENTRO MATERNO INFANTIL DO NORTE, PORTO, PORTUGAL
2- NEPHROLOGY SERVICE, CENTRO HOSPITALAR DO PORTO, PORTO, PORTUGAL
 
Introduction:

BK polyomavirus (BKV) is an emerging pathogen in immunocompromised individuals. It causes

tubulointersticial nephritis and ureteral stenosis in renal transplant recipients but, in the past, it was misdiagnosed due to clinical and histopathological similarities with acute rejection.

Material and methods:

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Results:

We report a case of a 17-year-old with a renal dysplasia leading to end-stage renal disease that received a kidney transplant in September/ 2013.

After 3 years, he returned to haemodialysis therapy due to chronic allograft dysfunction. He was highly sensitized with a calculated panel-reactive antibodies >85%. He received a second renal transplant from deceased-donor in August/2017. A positive BKV viremia was detected (level of 725 copies/ml) two weeks after transplantation. Imunossupression was lowered with the suspension of mycophenolate mofetil and maintenance therapy only with tacrolimus and prednisolone.Renal function remained stable until November/2017 (PCr 1.5mg/dL). Evaluation 8 days after the remotion of the ureteric stent showed an increased PCr 9.7mg/dL and haemodialysis was reinitiated. A renal biopsy revealed acute cellular rejection (Banff IB) and suggested coexistence of viral versus bacterial infection. He was started on metilprednisolone pulses followed with IV immunoglobulin. Renal ultrassound showed mild pyelic dilatation (renal pelvis with 15mm). Decompression with nephrostomy was performed with no improvement in renal function. On the 13th day of hospitalisation, SV40 antibody testing proved positive, confirming a BKV infection. Oral leflunamide was initiated (loading dose 100mg id for 3 days and maintenance with 20mg id). On the 30th day of hospitalisation percutaneous dilatation of the graft ureter was performed and total stenosis was documented. Renal function slowly improved, allowing the suspension of haemodialysis. On follow-up, renal function remained stable (PCr 2.2mg/dL) and BKV viremia was undetectable.

Conclusions:

The first step in the treatment of BKV infection is reduction in immunosuppression, but it may not suffice. Recently, leflunamide has emerged as an effective therapy against this agent. It is known to have both an imunossupressive and antiviral effect. In this case, a highly sensitized patient with a BK-polyoma disease, leflunamide proved to be an effective therapy.