Adenovirus infection of the renal allograft with sparing of pancreas graft function in the recipient of a combined kidney-pancreas transplant

The pathologic spectrum of adenovirus nephritis in the kidney allograft

Adenovirus nephritis (ADVN) is a rare and understudied complication of kidney transplantation. Unlike BK virus nephropathy (BKVN), our knowledge of clinicopathologic manifestations of ADVN remains rudimentary and essentially limited to case reports. To expand on this, we retrospectively studied 11 kidney transplant recipients with ADVN and compared their allograft biopsies to 33 kidney transplant recipients with BKVN using conventional microscopy and the 770 gene Nanostring Banff Human Organ Transplant Profiling Panel. Patients with ADVN had a median age of 44 years, were predominantly male, and developed ADVN at a median of 31 months post-transplantation. Eight patients presented with fever and ten had hematuria. The most common histologic manifestations included granulomas (82%), tubulocentric inflammation (73%), and tubular degenerative changes consistent with acute tubular necrosis (73%). During a median follow-up of 55 months after biopsy, three patients developed allograft failure from subsequent acute rejection. All seven patients with available follow-up PCR showed resolution of viremia at a median of 30 days after diagnosis. Compared to BKVN, ADVN demonstrated more granulomas and less tubulointerstitial scarring. On follow-up, patients with ADVN had more rapid clearance of viral DNA from plasma. Transcriptomic analyses showed that ADVN had increased expression of several pro-inflammatory transcriptomes, mainly related to innate immunity, was associated with increased expression of transcripts with inhibitory effects on inflammatory response and showed higher enrichment with neutrophils, which can cause aggressive but short-lasting damage. Thus, we demonstrate that, despite its association with aggressive neutrophil-rich inflammation, ADVN does not often lead to allograft failure. Hence, preventing subsequent acute rejection following resolution of ADVN may improve allograft survival.

Late presentation of adenovirus-induced hemorrhagic cystitis and ureteral obstruction in a kidney-pancreas transplant recipient

We report a late presentation of adenovirus-induced renal allograft and bladder infection causing azotemia and hemorrhagic cystitis in a patient 5 years after simultaneous kidney-pancreas transplantation. Adenovirus has been increasingly recognized as a cause of morbidity and mortality in both solid organ and stem cell transplant recipients. We wish to emphasize the importance of early detection, as treatment options involve reduction of immunosuppression, followed by the addition of antiviral agents and supportive care.

Fever, haematuria, and acute graft dysfunction in renal transplant recipients secondary to adenovirus infection: two case reports

We report two cases of adenoviral infection in kidney transplant recipients that presented with different clinical characteristics under similar demographic and posttransplant conditions. The first case presented with fever, gross haematuria, and acute graft dysfunction 15 days following renal transplantation. A graft biopsy, analyzed with immunohistochemistry, yielded negative results. However, the diagnosis was confirmed with blood and urine real-time PCR for adenovirus 3 days after the initial clinical manifestations. The immunosuppression dose was reduced, and ribavirin treatment was started, for which the patient quickly developed toxicity. Antiviral treatment allowed for transient response; however, a relapse occurred. The viral real-time PCR became negative upon immunosuppression reduction and administration of IVIG; graft function normalized. In the second case, the patient presented with fever and dysuria 1 month after transplantation. The initial imaging studies revealed graft enlargement and areas of hypoperfusion. In this case, the diagnosis was also confirmed with blood and urine real-time PCR for adenovirus 3 days after the initial clinical manifestations. Adenoviral nephritis was confirmed through a graft biopsy analyzed with light microscopy, immunohistochemistry, and PCR in frozen tissue. The immunosuppression dose was reduced, and IVIG was administered obtaining excellent clinical results along with a negative real-time PCR.

Early onset adenovirus infection after simultaneous kidney-pancreas transplant

Adenoviruses (AdV) are increasingly recognized as important viral pathogens in immunocompromised hosts. The clinical spectrum ranges from asymptomatic viremia to allograft dysfunction, and death. Most of the medical literature is on AdV infection in children and bone marrow transplant recipients. We report a case of AdV in an adult recipient in the first month after simultaneous kidney-pancreas transplant with thymoglobulin induction. This is a rare report of adenovirus infection after multiorgan transplant, and is unique in that it exhibited tissue invasive disease without any localizing signs or allograft dysfunction, while other cases in medical literature had invasive disease of the allograft with allograft dysfunction, failure, or death. In addition, this is the first report of a radiologic presentation of AdV nephritis.

Acute kidney injury requiring dialysis secondary to adenovirus nephritis in renal transplant recipient

Disseminated adenoviral infection is a serious problem, especially in an immunocompromised host. The disease carries a mortality rate reaching as high as 80%. It is seen most frequently in bone marrow transplant recipients, where it causes pneumonia and disseminated disease. In solid organ transplant recipients it causes graft infection. We report the case of a renal transplant recipient with disseminated adenoviral infection and acute kidney failure requiring dialysis. Reduction of immunosuppression and 1 dose of cidofovir were associated with resolution of viremia and viruria and return of kidney function to near baseline.

Adenovirus nephritis and obstructive uropathy in a renal transplant recipient: case report and literature review

We report an unusual case of adenoviral nephritis in a 45-year-old woman who presented with fever, gross haematuria, acute kidney injury and obstructive uropathy 17 months following renal transplantation. Adenoviral nephritis was confirmed with immunohistochemistry. We identified 10 other published cases of adenoviral nephritis proven by immunohistochemistry. Obstructive uropathy has been reported only once before in a renal transplant recipient with adenoviral nephritis. Contrary to other reports, this case series shows that renal function may not always recover to baseline following the acute adenoviral disease. Adenoviral nephritis should be considered in the renal transplant patient with fever, haematuria, acute kidney injury and hydronephrosis in both the early and late post-transplant periods.

A case of acute rejection with adenovirus infection after ABO-incompatible kidney transplantation

We report clinical and histopathologic findings of a case of acute rejection with adenovirus infection after kidney transplantation. A 63-yr-old woman with end-stage renal disease caused by lupus nephritis received an ABO-incompatible living kidney transplantation from her husband. On the 7th post-operative day (POD), she had fever, hematuria, and bladder irritation. Although she was treated with an antibiotic, the symptoms were not improved. We diagnosed adenovirus infection as positive with the urine shell vial method and blood PCR analysis. Cyclophosphamide was interrupted and immunoglobulin therapy was performed. However, urine output decreased and serum creatinine levels increased. An episode biopsy was performed on POD 20. We diagnosed acute antibody-mediated rejection. She was treated with plasma exchange for acute rejection and antiviral drug (rivabirin) for active adenovirus infection. However, the renal graft dysfunction was deemed irreversible and the renal graft was removed on POD 34. The graftectomy specimen showed acute rejection and acute tubular necrosis with adenovirus infection.

Adenovirus infections in transplant recipients

Adenoviruses are increasingly recognized as contributors to morbidity and mortality among stem cell and solid-organ transplant recipients. Clinical presentations range from asymptomatic viremia to respiratory and gastrointestinal disease, hemorrhagic cystitis, and severe disseminated illness. The limited clinical data available support the use of cidofovir for many of these illnesses. Prospective studies are needed to better understand the pathogenesis of and therapeutic options for adenoviral infections in this patient population.

Adenovirus tubulointerstitial nephritis presenting as a renal allograft space occupying lesion

This report describes a case of adenovirus infection in a renal allograft 36 days after transplantation that presented with transient macroscopic hematuria, prominent systemic features and acute renal dysfunction. The patient had persistent high fevers despite broad antibiotic cover. A CT scan demonstrated a new discrete space occupying lesion in the allograft, which was devoid of blood flow on Doppler sonography. A targeted renal biopsy showed florid and focal necrotizing interstitial nephritis with intranuclear tubular viral inclusions. Treatment with ganciclovir and reduction in immunosuppression resulted in a rapid improvement. Immunohistochemistry and electron microscopy confirmed adenovirus infection. This case demonstrates an uncommon presentation of necrotizing adenoviral nephropathy, which should be considered in cases of renal allograft mass lesions.

ADENOVIRUS NEPHRITIS IN HEMATOPOIETIC STEM-CELL TRANSPLANTATION

BACKGROUND

Although adenovirus (ADV) infections may involve many different organs, kidney infection is seldom reported in association with hematopoietic stem-cell transplantation (HSCT).

METHODS

In the present study, the diagnosis of ADV nephritis was established by the culture isolation of adenovirus or the immunocytochemical (ICC) demonstration of the adenoviral hexon protein. The clinical description of ADV nephritis was derived from retrospective review of clinical records to identify signs, symptoms, outcomes, and associated complications. ADV nephritis was characterized as a pathologic entity by the histologic and ICC analysis of tissue from the kidney and all other major organs to establish the distribution of the virus and the associated gross and microscopic alterations.

RESULTS

ADV nephritis was diagnosed in 21 HSCT patients, in 2 by biopsy and in 19 at autopsy. Focal signs of BK nephropathy were present in only one patient. Twenty had received allogeneic marrow and one had undergone autologous transplantation. Graft-versus-host disease was a risk factor. ADV nephritis was associated with acute renal failure in 90% of the infected patients. Prodromal symptoms included fever, hematuria, and flank pain. Adenoviruria was present in 78% of the patients. Kidney infection as determined by viral antigen ICC predominantly involved the tubular epithelial cells. ADV organ tropism was striking, with sero-types from subgenus B, cluster 2, primarily responsible for cases involving predominantly the urinary system. ADV infection was a major cause of death in 17 patients.

CONCLUSIONS

ADV nephritis is a specific renal complication in HSCT patients that can be diagnosed by renal biopsy in patients with hematuria and adenoviruria.

Adenovirus infection of a renal allograft

One month after renal transplantation, a 60-year-old man developed acute allograft dysfunction associated with gross hematuria and dysuria. Urinary cytological examination showed viral inclusion-bearing epithelial cells. A renal transplant biopsy specimen showed granulomatous interstitial nephritis, tubular necrosis, and ground glass-like intranuclear viral inclusion bodies in tubular cells caused by an adenovirus (ADV) infection. A reduction in baseline immunosuppressive therapy resulted in rapid normalization of allograft function and ultimately viral clearance. We report this case not only to illustrate an exceptional manifestation of an ADV infection in a renal allograft, but also to highlight the beneficial effect of reduction in immunosuppressive therapy on viral replication and clinical outcome.

Acute Adenoviral Infection of a Graft by Serotype 35 Following Renal Transplantation

Adenoviral infections of immunocompetent patients usually present as self-limiting pharyngitis, gastroenteritis, urocystitis, or conjunctivitis. In immunosuppressed patients, development of the illness can be severe, even life-threatening or fatal, and therapeutical intervention is difficult. Previous case reports of adenoviral infections after kidney transplantation have described a symptomatology of hemorrhagic cystitis, fever, renal dysfunction, and rarely fatal systemic dissemination. Here we report on a 46-year-old female renal transplant recipient suffering from adenoviral serotype 35 nephritis of the donor organ 29 days after transplantation. In this case, the main symptoms of the adenoviral infection were high fever and progressive renal failure of the transplanted organ. At the peak of the clinical symptoms, owing to histological and immunohistochemical evaluations of a kidney biopsy, we were able to establish the diagnosis in time so that adequate therapy could be employed. Immunosuppression was reduced and modified, and a self-limiting course of the infection was observed, followed by significant improvement of graft function. Subsequent to histological diagnosis, adenoviral particles were isolated from urine and identified as adenovirus serotype 35. Adenoviral nephritis of the transplanted organ should be considered in the differential diagnosis of persistent anuria after kidney transplantation. Our case highlights the importance of applying all possible diagnostic techniques, including histological evaluation of renal biopsies.