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Du ZS, Xie XH, Hu JJ, Fang Y, Ye L. Ultrasound for monitoring different stages of post-transplant lymphoproliferative disorder in a transplanted kidney: A case report and review of the literature. Medicine (Baltimore) 2024; 103:e36206. [PMID: 38394510 DOI: 10.1097/md.0000000000036206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2024] Open
Abstract
RATIONALE Post-transplant lymphoproliferative disorder (PTLD) is a well-recognized, but uncommon complication in patients with kidney transplantation, which poses challenges in diagnosis and poor prognosis due to its low incidence and nonspecific clinical manifestations. As a routine follow-up examination method for kidney transplant patients, ultrasound (US) plays a significant role in the diagnosis of PTLD. Therefore, it is critical to evaluate the ultrasonic characteristics of PTLD in transplanted kidney patients for early detection and diagnosis. PATIENT CONCERNS A 59-year-old female patient was unexpectedly found with a mass in the hilum of the transplanted kidney 12th month after transplantation, which gradually grew up in the following 4 months. The latest US examination found hydronephrosis. Contrast-enhanced ultrasound (CEUS) demonstrated a hypo-enhancement pattern in arterial and parenchymal phases and showed a new irregular area lacking perceivable intensification within the mass, which was considered necrosis. Meanwhile, the patient developed an acute increase in serum creatinine from 122 to 195 μmol/L. DIAGNOSIS A US-guided biopsy was conducted with the final pathological diagnosis of PTLD (polymorphic). INTERVENTIONS After receiving 3 times of rituximab and symptomatic treatment, blood creatinine returned to normal but the mass was still progressing in the patient. Therefore, the treatment approach was modified to immune-chemotherapy. OUTCOMES The patient was in a stable condition to date. LESSONS PTLD is a rare complication in a transplanted kidney. US and CEUS are the preferred imaging methods in renal transplant patients due to their good repeatability and no nephrotoxicity. This case demonstrates that continuous dynamic monitoring by using US and CEUS has significant value in the detection and diagnosis of PTLD in a transplanted kidney, suggesting early clinical intervention to avoid further progression.
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Affiliation(s)
- Zu-Sheng Du
- Department of Ultrasound, Ningbo Yinzhou No.2 Hospital, Ningbo, China
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2
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Wei TR, Agarwal G, Rosenblum F, Kew CE. Perinephric Transplant Myelolipoma: A Case Report of a Rare Entity. Transplant Proc 2023; 55:1917-1920. [PMID: 37625934 DOI: 10.1016/j.transproceed.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 07/31/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Myelolipomas are benign tumors usually found in adrenal glands. They can also be found extra-adrenally, either in 1 or multiple locations. Perinephric transplant myelolipoma has rarely been reported in the English literature. There's only been 1 instance of such a case reported in a kidney transplant patient, which was found on the explanted kidney. We report a case involving an asymptomatic patient with an ill-defined perinephric transplant mass. METHODS The mass was then identified as myelolipoma on biopsy. The patient was then managed conservatively with serial imaging and laboratory testing. RESULTS At the time of our report, the patient continues to have stable renal function and is doing well 24 months after the mass was first identified. CONCLUSIONS We report the first case of perinephric transplant myelolipoma in a patient with ongoing stable renal allograft function. Based on our case report, we recommended that conservative management with serial imaging and routine testing be considered for patients with perinephric transplant myelolipoma.
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Affiliation(s)
- Tina Ruoting Wei
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Gaurav Agarwal
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Frida Rosenblum
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Clifton E Kew
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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3
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D'Costa MR, King RL, Alexander MP, Zhang P, Issa N, Dingli D, Amer H, Singh D, Leung N, Sukov WR, Dean PG, Habermann TM, Kukla A. Epstein Barr Virus-Negative Lymphoplasmacytic Proliferation Limited to the Renal Allograft: A Unique Presentation of a Rare Disease. Kidney Int Rep 2021; 6:2223-2227. [PMID: 34386673 PMCID: PMC8343792 DOI: 10.1016/j.ekir.2021.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/20/2021] [Accepted: 05/17/2021] [Indexed: 10/25/2022] Open
Affiliation(s)
- Matthew R D'Costa
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Rebecca L King
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mariam P Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Pingchuan Zhang
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Naim Issa
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - David Dingli
- Department of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hatem Amer
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Devender Singh
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA.,Department of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - William R Sukov
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick G Dean
- Department of Transplantation Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Aleksandra Kukla
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
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Di Napoli ML, Rohan V, Nadig SN, Lin A. Small Bowel Perforation as the Initial Manifestation of Post-Transplant Lymphoproliferative Disorder in a Kidney and Pancreas Transplant Recipient: A Case Report. Transplant Proc 2020; 52:2827-2830. [PMID: 32900475 DOI: 10.1016/j.transproceed.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/02/2020] [Indexed: 11/16/2022]
Abstract
Post-transplant lymphoproliferative disorder (PTLD) comprises a broad spectrum of diseases and is a rare but serious complication of solid organ transplantation. We report the case of a 45-year-old simultaneous pancreas and kidney (SPK) transplant recipient with diffuse, early-onset PTLD, manifesting as jejunal perforation at 6 months after transplantation. The patient underwent urgent small bowel resection of the affected portion of jejunum. The surgical pathology report was significant for diffuse large B-cell lymphoma. Subsequently, the patient underwent a full workup, including upper and lower endoscopy and whole-body positron emission tomography that revealed involvement of the axial skeleton and multiple abdominal organs with sparing of the grafts. He was treated with rituximab and intrathecal methotrexate for central nervous system prophylaxis. The patient experienced complete resolution of disease by positron emission tomography 8 months after initial presentation. We found no previous report in the literature of intestinal perforation as the initial presentation of PTLD in SPK transplant recipients.
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Affiliation(s)
- Marissa L Di Napoli
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Vinayak Rohan
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Satish N Nadig
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Angello Lin
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC, United States.
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5
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Short-term Pharmacological Inhibition of MyD88 Homodimerization by a Novel Inhibitor Promotes Robust Allograft Tolerance in Mouse Cardiac and Skin Transplantation. Transplantation 2017; 101:284-293. [PMID: 27607533 DOI: 10.1097/tp.0000000000001471] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Most strategies for antirejection and tolerance induction in clinical transplantation have focused on modifying adaptive immunity, it is unclear whether pharmacological suppressing the innate immune system can promote transplant tolerance. METHODS We inhibited innate immunity by using our self-generated inhibitor of myeloid differentiation factor 88 (MyD88), TJ-M2010-5, and investigated its therapeutic effects and mechanisms in cardiac and skin transplant models. RESULTS TJ-M2010-5 directly and indirectly interacted with the Toll/IL-1R domain of MyD88, inhibiting MyD88 homodimerization. In vitro, TJ-M2010-5 inhibited maturation of dendritic cells, which suppressed nuclear translocation of NF-κB and T cell activation. In vivo, short-term (10 days) monotherapy of TJ-M2010-5 resulted in long time survival of 50% of the cardiac allografts, and longer-term (14 days) combination treatment of TJ-M2010-5 with CD154 mAb resulted in survival of 29% of skin allografts, which outperformed far more than CsA did and stimulated the proliferation of CD4CD25FoxP3 Regulatory T cells in recipient mice. CONCLUSIONS Pharmacological inhibition of MyD88 signaling by this novel inhibitor TJ-M2010-5 shows a powerful anti-rejection effect, which may have therapeutic potential in clinical transplantation. The inhibition of both innate and adaptive immunity may be necessary for tolerance induction in nonsolid organs.
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6
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Le J, Durand CM, Agha I, Brennan DC. Epstein-Barr virus and renal transplantation. Transplant Rev (Orlando) 2016; 31:55-60. [PMID: 28089555 DOI: 10.1016/j.trre.2016.12.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 12/12/2016] [Accepted: 12/25/2016] [Indexed: 01/22/2023]
Abstract
Epstein-Barr virus (EBV) is a gamma herpesvirus associated with diseases ranging from asymptomatic viremia to post-transplant malignancies in kidney transplant recipients. EBV specifically is associated with post-transplantation lymphoproliferative disorder (PTLD), in kidney transplant recipients, with increased risk in EBV seronegative patients with EBV seropositive donors on intensified immunosuppression. The diagnosis of PTLD relies on clinical suspicion plus tissue biopsy with polymerase chain reaction (PCR) testing of blood currently used for risk determination in high-risk recipients. Therapeutic strategies for PTLD include reduction of immunosuppression, chemotherapy and rituximab, and consideration of sirolimus-based immunosuppression. Antivirals such as ganciclovir are used to prevent reactivation of cytomegalovirus and other herpes viruses but are not onco-therapeutic. Radiation therapy or surgery is indicated for bulky, disseminated or recalcitrant disease. Prognosis varies depending on the type of malignancy identified and stage of disease.
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Affiliation(s)
- Jade Le
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States
| | - Christine M Durand
- Johns Hopkins Medical Institute, 1830 East Monument Street, Room 450D, Baltimore, MD 21287, United States
| | - Irfan Agha
- Dallas Renal Group, 3571 W. Wheatland Road, Suite 101, Dallas, TX 75237, United States
| | - Daniel C Brennan
- Washington University School of Medicine, 660 S Euclid Ave, St. Louis, MO 63110, United States.
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8
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Lampe A, Duddalwar VA, Djaladat H, Aron M, Gulati M. Contrast-enhanced ultrasound findings of post-transplant lymphoproliferative disorder in a transplanted kidney: A case report and literature review. J Radiol Case Rep 2015; 9:26-34. [PMID: 26629291 DOI: 10.3941/jrcr.v9i10.2602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Post-transplant lymphoproliferative disorder occurs in approximately one percent of kidney transplant recipients. We evaluated a seventy-seven year-old man with a solid mass in his transplant kidney. On contrast enhanced ultrasound, the mass enhanced but remained persistently hypovascular throughout exam. The enhancement pattern of the mass differed from that typical of clear cell renal cell carcinoma, the main differential diagnosis. Final pathology after partial nephrectomy confirmed post-transplant lymphoproliferative disorder. This is the first report of contrast enhanced ultrasound findings in a renal mass diagnosed as post-transplant lymphoproliferative disorder. Contrast enhanced ultrasound has a promising role in imaging of renal masses, particularly relevant in transplant patients due to the lack of nephrotoxicity.
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Affiliation(s)
- Alyssa Lampe
- Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Vinay A Duddalwar
- Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Hooman Djaladat
- Department of Urology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Manju Aron
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Mittul Gulati
- Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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9
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Bennett WM, Batiuk TD, McEvoy KM, Douzdjian V, Hyde J, Shaut C, Segal GM. Early Post-transplant Lymphoproliferative Disease in the Donor Ureter Without Systemic Involvement: A Case Report. Transplant Proc 2015; 47:2301-3. [PMID: 26361705 DOI: 10.1016/j.transproceed.2015.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Post-transplant lymphoproliferative disease is a serious complication of renal transplantation. Major risk factors include Epstein-Barr virus (EBV) seronegativity and induction immunosuppression with lymphocyte-depleting agents. RESULTS We present a case of a 50-year year-old woman with very early onset PTLD confined to the donor ureter. Phenotypic studies on the tumor material reveal that the lymphoma was most likely of donor origin. A complete staging workup including the kidney allograft was negative for any other sites of involvement. CONCLUSIONS This case, which had a fatal outcome, emphasizes the risk of renal transplantation in BV-negative individuals when given induction with lymphocyte-depleting drugs.
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Affiliation(s)
- W M Bennett
- Legacy Transplant Services, Legacy Good Samaritan Medical Center, Portland, Oregon, United States.
| | - T D Batiuk
- Legacy Transplant Services, Legacy Good Samaritan Medical Center, Portland, Oregon, United States
| | - K M McEvoy
- Legacy Transplant Services, Legacy Good Samaritan Medical Center, Portland, Oregon, United States
| | - V Douzdjian
- Legacy Transplant Services, Legacy Good Samaritan Medical Center, Portland, Oregon, United States
| | - J Hyde
- Legacy Pathology Services, Legacy Good Samaritan Medical Center, Portland, Oregon, United States
| | - C Shaut
- Laboratory of Immunogenetics and Transplantation, Oregon Health & Science University, Portland, Oregon, United States
| | - G M Segal
- Compass Oncology, Portland, Oregon, United States
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10
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Extravascular complications following abdominal organ transplantation. Clin Radiol 2015; 70:898-908. [DOI: 10.1016/j.crad.2015.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 03/03/2015] [Accepted: 04/09/2015] [Indexed: 12/15/2022]
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11
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Gao C, Peng L, Peng F, Tuo T, Li D. Post-transplant lymphoproliferative disorder presenting as a tumor adjacent to the renal allograft: A case report and review of the literature. Oncol Lett 2014; 8:2607-2610. [PMID: 25364435 PMCID: PMC4214511 DOI: 10.3892/ol.2014.2586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 09/19/2014] [Indexed: 11/19/2022] Open
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is a potentially fatal complication of solid organ transplantation. The current report presents the case of a 42-year-old male who developed PTLD within the first year following renal transplantation. The disorder manifested as a tumor adjacent to the lower pole of the renal allograft and resulted in urinary obstruction. Durable complete remission was achieved as a result of surgical resection followed by a reduction in immunosuppression and low-dose rituximab-based chemotherapy, indicating that this therapeutic strategy may be safe and effective for the treatment of specific cases of localized and resectable PTLD.
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Affiliation(s)
- Chen Gao
- Department of Urological Organ Transplantation, Second Xiangya Hospital, Central South University, Changsha, Hunan 41011, P.R. China
| | - Longkai Peng
- Department of Urological Organ Transplantation, Second Xiangya Hospital, Central South University, Changsha, Hunan 41011, P.R. China
| | - Fenghua Peng
- Department of Urological Organ Transplantation, Second Xiangya Hospital, Central South University, Changsha, Hunan 41011, P.R. China
| | - Ting Tuo
- Department of Urological Organ Transplantation, Second Xiangya Hospital, Central South University, Changsha, Hunan 41011, P.R. China
| | - Daiqiang Li
- Department of Pathology, Second Xiangya Hospital, Central South University, Changsha, Hunan 41011, P.R. China
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12
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Moir JAG, Simms RJ, Wood KM, Talbot D, Kanagasundaram NS. Posttransplant lymphoproliferative disorder presenting as multiple cystic lesions in a renal transplant recipient. Am J Transplant 2012; 12:245-9. [PMID: 22244123 DOI: 10.1111/j.1600-6143.2011.03761.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We report a case of a 67-year-old man who experienced allograft dysfunction following a renal transplantation from a donation after cardiac death. The postoperative course was initially complicated by episodes of E. coli urinary sepsis causing pyrexia and a raised creatinine level. Ultrasound scanning 5 weeks posttransplant revealed mild hydronephrosis with several parenchymal cystic areas measuring up to 2 cm with appearances suggestive of fungal balls. Aspirated fluid again grew Escherichia coli, and this was treated with the appropriate antimicrobial therapy. The patient continued to have episodes of culture-negative sepsis; therefore, a computed tomography scan was performed 6 months posttransplant, which revealed multiple lesions in the renal cortex as well as liver and spleen. Subsequent biopsy revealed an Epstein-Barr virus-driven lymphoproliferation consistent with a polymorphic posttransplantation lymphoproliferative disorder (PTLD). This rare case of PTLD presenting as multiple renal, hepatic and splenic lesions emphasizes the need for a high index of clinical suspicion for this condition. Abnormal para-renal allograft masses should be biopsied to allow swift and effective management of a disease that can disseminate and become significantly more challenging to manage.
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Affiliation(s)
- J A G Moir
- Renal Transplant Unit, Newcastle Upon Tyne Hospitals NHS Foundation Trust, UK.
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13
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Abstract
With the advent of more potent immunosuppressive regimens, the incidence of acute rejection following renal transplantation has declined sharply in recent years. In spite of this, long-term graft outcomes remain suboptimal because of relentless attrition by cumulated insults to the allograft. As acute rejection rates have declined, other causes of graft injury and loss have recently emerged. Among these, infectious diseases remain a persistent threat and can be associated with allograft dysfunction. This group includes nephropathy due to polyoma (BK) virus infection, cytomegalovirus disease, and bacterial infection (the latter most commonly arising from the urinary tract). Rarer infectious causes of chronic allograft dysfunction include cryoglobulinemia associated with hepatitis C, Epstein-Barr virus-associated posttransplant lymphoproliferative disease, and direct cytotoxicity from adenoviral infection or parvovirus B19.
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Affiliation(s)
- Peter J Dupont
- Department of Nephrology and Transplantation, Royal Free Hospital, London, UK.
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14
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Morgans AK, Reshef R, Tsai DE. Posttransplant Lymphoproliferative Disorder Following Kidney Transplant. Am J Kidney Dis 2010; 55:168-80. [DOI: 10.1053/j.ajkd.2009.09.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Accepted: 09/30/2009] [Indexed: 01/20/2023]
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15
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Avoiding pitfalls: what an endoscopist should know in liver transplantation--part II. Dig Dis Sci 2009; 54:1386-402. [PMID: 19085103 DOI: 10.1007/s10620-008-0520-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Accepted: 08/27/2008] [Indexed: 02/07/2023]
Abstract
Over the last decade the number of patients undergoing transplantation has increased. At the same time, effective peri- and postoperative care and better surgical techniques have resulted in greater numbers of recipients achieving long-term survival. Identification and effective management in the form of adequate treatment is essential, since any delay in diagnosis or treatment may result in graft loss or serious threat to patient's life. Various aspects of endoscopic findings that can be commonly encountered among liver transplant recipients are discussed herein. Topics include: persistent and/or recurrent esophageal varices, reflux, Candida or cytomegalovirus (CMV) esophagitis, esophageal neoplasms, posttransplant peptic ulcer, biliary complications, posttransplant lymphoproliferative disorder (PTLD), Kaposi's sarcoma, CMV colitis and inflammatory bowel disease, colonic neoplasms, Clostridium difficile infection, and graft versus host disease (GVHD).
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Basic-Jukic N, Kes P, Coric M, Kastelan Z, Pasini J, Bubic-Filipi L. Posttransplant lymphoproliferative disorder in the wall of a lymphocele: a case report. Transplant Proc 2009; 41:1966-8. [PMID: 19545769 DOI: 10.1016/j.transproceed.2008.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2008] [Accepted: 11/14/2008] [Indexed: 10/20/2022]
Abstract
Posttransplant lymphoproliferative disorder (PTLD) is a well-known complication of renal transplantation with increased incidence after introduction of more powerful immunosuppressive drugs. Presenting symptoms are nonspecific; some patients may be entirely asymptomatic. Herein we have reported a case of PTLD arising in the lymphocele wall presenting with B-symptoms and deterioration of graft function. A 62-year-old-female with end-stage renal disease secondary to Balkan endemic nephropathy and positive Epstein-Barr virus (EBV) serology before transplantation received a renal transplant from a deceased donor. Six months after transplantation she was admitted to the hospital with a 1-week history of malaise, weight loss, anorexia, night sweats, and febrile episodes. Multisliced computed tomography demonstrated a cystic structure at the renal hilus. Graft function deteriorated, so the patient underwent puncture of the lymphocele. Urgent graftectomy was necessary to stop the bleeding. Pathohistology demonstrated EBV-positive, CD20-positive PTLD. The patient received 6 cycles of chemotherapy and continued on hemodialysis. We concluded that a high index of suspicion for PTLD should be maintained when evaluating lymphoceles arising in the later posttransplantation period. Irrespective of their imaging features, biopsy should be performed to exclude PTLD.
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17
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Post-transplant lymphoproliferative disorder (PTLD) presenting as painful lymphocele 12 years after a cadaveric renal transplant. Int Urol Nephrol 2008; 40:547-50. [DOI: 10.1007/s11255-008-9367-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Accepted: 03/04/2008] [Indexed: 10/22/2022]
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18
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Chan ALF, Wang HY. Epstein-barr virus-related post-transplant lymphoproliferative disorder in a renal transplant recipient treated with tacrolimus and antithymocyte globulin. Clin Drug Investig 2007; 23:281-3. [PMID: 17535041 DOI: 10.2165/00044011-200323040-00008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Agnes L F Chan
- Pharmacy Department, Chi Mei Medical Center, Tainan, Taiwan
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Bakker NA, van Imhoff GW, Verschuuren EAM, van Son WJ. Presentation and early detection of post-transplant lymphoproliferative disorder after solid organ transplantation. Transpl Int 2007; 20:207-18. [PMID: 17291214 DOI: 10.1111/j.1432-2277.2006.00416.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is a serious and still frequently observed complication of solid organ transplantation. Despite the recent introduction of anti B-cell monoclonal antibody therapy (rituximab) for treatment of PTLD, mortality rates remain high. Because PTLD often presents in a nonspecific way in clinically unsuspected patients, it is a major challenge to diagnose PTLD at an early stage. Epstein-Barr virus (EBV)-DNA load monitoring is a promising tool for the identification of patients at risk for PTLD development. However, there are some limitations of this method, and not all patients at risk for PTLD can be identified by EBV-DNA measurements alone. Therefore, it is of major importance to recognize early clinical signs and symptoms of PTLD. In this review, risk factors for PTLD development, disease presentation, and methods for early detection will be discussed. Special attention is given to allograft and digestive tract localization and the relation with time of onset of PTLD. The value and pitfalls of EBV-DNA load monitoring are discussed. In addition, because fluorodeoxyglucose (FDG)-positron emission tomography (PET) has shown to be a powerful tool for staging and response evaluation of malignant lymphoma, the role of FDG-PET for early diagnosis and staging of PTLD is addressed.
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Affiliation(s)
- Nicolaas A Bakker
- Department of Haematology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
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21
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Moudouni SM, Tligui M, Doublet JD, Haab F, Gattegno B, Thibault P. Lymphoproliferative disorder presenting as a tumor of the renal allograft. Int Urol Nephrol 2006; 38:779-82. [PMID: 17160544 DOI: 10.1007/s11255-006-0067-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Accepted: 02/28/2006] [Indexed: 10/23/2022]
Abstract
Post-transplant lymphoproliferative diseases (PTLDs) constitute a group of potentially life-threatening complications in solid organ transplantation, occurring in 1-2% of kidney transplant recipients. The absolute number of cases occurring at each transplant center remains small, making it difficult to assess incidence, prognosis, and treatment. We report a case of post-transplant lymphoproliferative disorder that developed in the allograft renal parenchyma 2 years after renal transplantation. This case implies that partial nephrectomy may be a safe and effective treatment protocol for renal lymphoma in allograft kidneys.
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Affiliation(s)
- S M Moudouni
- Department of Urologic Surgery, Tenon Hospital, Paris, France.
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22
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Aalto SM, Juvonen E, Tarkkanen J, Volin L, Ruutu T, Mattila PS, Piiparinen H, Knuutila S, Hedman K. Lymphoproliferative disease after allogeneic stem cell transplantation--pre-emptive diagnosis by quantification of Epstein-Barr virus DNA in serum. J Clin Virol 2004; 28:275-83. [PMID: 14522066 DOI: 10.1016/s1386-6532(03)00022-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Lymphoproliferative disease (PTLD) is a life-threatening complication of organ transplantation. In matched, allogeneic, non-T-cell-depleted stem-cell transplantations (SCT) the disease develops early but has been thought to be rare. OBJECTIVES We determined by strict histopathological criteria the incidence of fatal Epstein-Barr-virus (EBV)-related PTLD in a large number of SCT, and assessed the diagnostic value of a real-time quantitative polymerase chain reaction (qPCR) for EBV-DNA in serum specimens. STUDY DESIGN Of the 257 SCT performed in Helsinki during 1994-1999, 132 (51%) recipients were alive and 125 (49%) had succumbed by June 2001. The necropsies were analyzed for EBV-related PTLD as evidenced by disseminated lymphocytic infiltrates labeled histochemically for antigens and RNA (EBER 1 and 2) detectable by in situ technology. From a subset of the PTLD cases (N=12) and a series of corresponding stem-cell recipient controls (N=36), consecutive samples of serum (N=103 and 364, respectively) were studied by qPCR for EBV-DNA, and the clinical data were reviewed. RESULTS The post-mortem analysis revealed 18 cases of PTLD (14% of the deceased), all of whom had received intensive immunosuppressive treatment including anti-thymocyte globulin for treatment or prophylaxis of graft versus host disease (GVHD). By using qPCR all the PTLD patients became EBV-DNA positive, in progressively rising copy numbers. EBV-DNA was first detectable 70 (median; range 24-154) days after SCT or 23 (4-86) days before death; i.e. earlier than the symptoms which appeared 15 (2-85) days before death. Among the SCT controls, EBV-DNA occurred sporadically (in only 3.9% sera). CONCLUSIONS qPCR for EBV-DNA in serum is a highly sensitive (100%) and specific (96%) diagnostic approach. Intensely immunosuppressed stem-cell recipients are at a great risk of developing PTLD, and should be carefully monitored for EBV-DNA, for pre-emptive treatment of this life-threatening disorder.
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Affiliation(s)
- Sanna M Aalto
- Department of Virology, Haartman Institute, University of Helsinki and Helsinki University Central Hospital, FIN-00290 Helsinki, Finland
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23
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Abstract
We used the Collaborative Transplant Study database to analyze the incidence, risk, and impact of malignant lymphomas in approximately 200,000 organ transplant recipients. Over a 10-year period, the risk in renal transplant recipients was 11.8-fold higher than that in a matched nontransplanted population (p<0.0001). The majority of lymphomas were diagnosed after the first post-transplant year. Heart-lung transplants showed the highest relative risk (RR 239.5) among different types of organ transplants. In kidney recipients, immunosuppression with cyclosporine did not confer added risk compared with azathioprine/steroid treatment, whereas treatment with FK506 increased the risk approximately twofold. Induction therapy with OKT3 or ATG, but not with anti-IL2 receptor antibodies, increased the risk of lymphoma during the first year. Antirejection therapy with OKT3 or ATG also increased the risk. First-year mortality in renal and heart transplant patients with lymphoma was approximately 40% and 50%, respectively, and showed no improvement in recent years. A pattern of preferential localization to the vicinity of the transplant was noted, and the prognosis of the patient was related to localization. This study highlights the continuing risk for lymphoma with time post-transplantation, the contribution of immunosuppression to increased risk, and continuing poor outcomes in patients with post-transplant lymphoma.
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Affiliation(s)
- Gerhard Opelz
- Department of Transplantation Immunology, University of Heidelberg, Heidelberg, Germany.
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Bustami RT, Ojo AO, Wolfe RA, Merion RM, Bennett WM, McDiarmid SV, Leichtman AB, Held PJ, Port FK. Immunosuppression and the risk of post-transplant malignancy among cadaveric first kidney transplant recipients. Am J Transplant 2004; 4:87-93. [PMID: 14678038 DOI: 10.1046/j.1600-6135.2003.00274.x] [Citation(s) in RCA: 232] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The success of renal transplantation may be counterbalanced by serious adverse medical events. The effect of immunosuppression on the incidence of de novo neoplasms among kidney recipients should be monitored continuously. Using data from the Scientific Registry of Transplant Recipients, we studied the association of induction therapy by immunosuppression with antilymphocyte antibodies, with the development of de novo neoplasms. The study population included more than 41 000 recipients who received a cadaveric first kidney transplant after December 31, 1995, and were followed through February 28, 2002. Using Cox regression models, we estimated time to development of two types of malignancy: de novo solid tumors and post-transplant lymphoproliferative disorder (PTLD). We made adjustments for several patient demographic factors and comorbidities. Induction therapy was significantly associated with a higher relative risk (RR) of PTLD (RR = 1.78, p < 0.001), but not with a greater likelihood of de novo tumors (RR = 1.07, p = 0.42). Treatment with maintenance tacrolimus vs. cyclosporine showed a significantly different RR of developing de novo tumors for recipients with induction than for those not receiving induction (p = 0.024). These new estimates of the magnitude of malignancy risk associated with induction therapy may be useful for clinical practice.
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Affiliation(s)
- Rami T Bustami
- Scientific Registry of Transplant Recipients/University Renal Research and Education Association, Ann Arbor, MI, USA.
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25
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Myron Kauffman H, McBride MA, Cherikh WS, Spain PC, Hanto DW, Delmonico FL. Donor-related malignancies. Transplant Rev (Orlando) 2002. [DOI: 10.1053/trte.2002.128240] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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26
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Abstract
Sonography is a simple, inexpensive, and readily available imaging modality that has become an essential component of the management of renal transplantation. It is indicated in almost all patients with acute renal failure and also is useful in the evaluation of pain, infection, and hematuria and the performance of percutaneous biopsy. Although many aspects of sonography are similar in native and transplanted kidneys, there are important differences and problems unique to the renal allograft, which form the basis for this review. The anatomy of renal transplantation and changes that accompany parenchymal disorders are discussed, but particular attention focuses on problems related to the urinary tract, fluid collections, and vascular disorders. By becoming more familiar with transplant sonography, nephrologists will be better able to incorporate this indispensable tool into the care of their patients.
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Affiliation(s)
- W Charles O'neill
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA.
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27
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Petit B, Le Meur Y, Jaccard A, Paraf F, Robert CL, Bordessoule D, Labrousse F, Drouet M. Influence of host-recipient origin on clinical aspects of posttransplantation lymphoproliferative disorders in kidney transplantation. Transplantation 2002; 73:265-71. [PMID: 11821742 DOI: 10.1097/00007890-200201270-00020] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Posttransplantation lymphoproliferative disorder (PTLD) is a well-known complication of immunosuppression associated with solid organ transplantation. The donor or host origin of PTLD may influence the outcome of the disease as it has been reported that a donor origin may be associated with a better prognosis. The aim of the study was to determine the origin (recipient or donor) of 12 PTLD occurring in kidney transplant recipients and to correlate the results with clinical findings. METHODS Origin of PTLD was determined using HLA DRB1 molecular typing, analysis of multiple short-tandem repeat microsatellite loci, and HLA class I antigen expression by immunohistochemistry. RESULTS Combining the three techniques, we found that eight cases originated from the recipient and four cases originated from the donor. The results of the three techniques were concordant and altogether assigned the origin of the tumors. All the donor-origin PTLD were strictly localized to the kidney graft, developed after a mean time of 5 months after transplantation, and regressed after reduction of immunosuppression. In contrast, seven of the eight recipient-origin PTLD presented as multisystemic disease, occurred a mean time of 75.7 months after the transplantation, and had a worse outcome (mortality, five deaths of eight patients, 62.5%). CONCLUSIONS These results suggest that PTLD originating from the donor arise in the first year after transplantation into the graft, and that recipient-origin PTLD develop later as an invasive disease. Because it permits simultaneously the analysis of cell morphology and tumor origin, immunohistochemistry is a more reliable technique in the case of graft tumors associated with allograft rejection. The determination of the origin of the tumors seems to be of value in the management of PTLD to predict the outcome and to adapt therapy.
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Affiliation(s)
- Barbara Petit
- Department of Pathology, Dupuytren Hospital, Limoges, France
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28
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Abstract
Because of its direct multiplanar capability, superb soft tissue contrast and ability to obtain dynamic three-dimensional angiograms using contrast agents without nephrotoxicity, magnetic resonance (MR) imaging and magnetic resonance angiography are ideal techniques for evaluating renal transplants. The following pictorial essay reviews the normal MR appearance of the transplant kidney as well as parenchymal, vascular, and peritransplant complications.
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Affiliation(s)
- Y C Fang
- Department of Radiology, University of Pennsylvania Medical Center, Philadelphia, PA 19104-4283, USA
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29
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POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER PRESENTING AS A LARGE TUMOR OF THE RENAL ALLOGRAFT. J Urol 2001. [DOI: 10.1097/00005392-200105000-00050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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KOJIMA YASUYUKI, TAKAHARA SHIRO, KOKADO YUKITO, KAKIYA RYUSUKE, YASUDA JUNKO, MORI HIROSHI. POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER PRESENTING AS A LARGE TUMOR OF THE RENAL ALLOGRAFT. J Urol 2001. [DOI: 10.1016/s0022-5347(05)66363-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- YASUYUKI KOJIMA
- From the Departments of Urology, Inoue Hospital and Osaka University Medical School, Departments of Internal Medicine, Inoue Hospital and Osaka Prefectural Hospital and Department of Pathology, Osaka Medical College, Osaka, Japan
| | - SHIRO TAKAHARA
- From the Departments of Urology, Inoue Hospital and Osaka University Medical School, Departments of Internal Medicine, Inoue Hospital and Osaka Prefectural Hospital and Department of Pathology, Osaka Medical College, Osaka, Japan
| | - YUKITO KOKADO
- From the Departments of Urology, Inoue Hospital and Osaka University Medical School, Departments of Internal Medicine, Inoue Hospital and Osaka Prefectural Hospital and Department of Pathology, Osaka Medical College, Osaka, Japan
| | - RYUSUKE KAKIYA
- From the Departments of Urology, Inoue Hospital and Osaka University Medical School, Departments of Internal Medicine, Inoue Hospital and Osaka Prefectural Hospital and Department of Pathology, Osaka Medical College, Osaka, Japan
| | - JUNKO YASUDA
- From the Departments of Urology, Inoue Hospital and Osaka University Medical School, Departments of Internal Medicine, Inoue Hospital and Osaka Prefectural Hospital and Department of Pathology, Osaka Medical College, Osaka, Japan
| | - HIROSHI MORI
- From the Departments of Urology, Inoue Hospital and Osaka University Medical School, Departments of Internal Medicine, Inoue Hospital and Osaka Prefectural Hospital and Department of Pathology, Osaka Medical College, Osaka, Japan
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31
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Lopez-Ben R, Smith JK, Kew CE, Kenney PJ, Julian BA, Robbin ML. Focal posttransplantation lymphoproliferative disorder at the renal allograft hilum. AJR Am J Roentgenol 2000; 175:1417-22. [PMID: 11044055 DOI: 10.2214/ajr.175.5.1751417] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This report describes the imaging characteristics of focal posttransplantation lymphoproliferative disorder. CONCLUSION Posttransplantation lymphoproliferative disorder may be limited to the allograft. A focal complex mass in the renal allograft hilum surrounding the main renal blood vessels is a common finding and can be visualized with sonography. MR imaging can help increase diagnostic confidence.
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Affiliation(s)
- R Lopez-Ben
- Department of Radiology, The University of Alabama Hospitals, The University of Alabama at Birmingham, 619 19th St. South, Birmingham, AL 35294, USA
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