Ureteral stenosis due to recurrent Wegener's granulomatosis after kidney transplantation

Granulomatosis with Polyangiitis Masquerading as Renal Mass: Case Report and Literature Review

Wegener's granulomatosis or granulomatosis with polyangiitis (GPA) is multisystemic vasculitis. Kidney involvement in GPA often presents with rapidly progressive renal failure and requires urgent treatment. A 60-year-old female presented with prolonged history of fever, generalized weakness, decreased appetite, and weight loss over 4 months. Her renal function was normal; urine culture was sterile. On further evaluation, she was found to have large, hypodense solid lesion in mid pole of the right kidney on CECT. CT guided renal biopsy was done, which showed granulomatous interstitial nephritis with focal crescents. On further evaluation, she was found to have high titers of anti-MPO antibody. She was started on steroid and methotrexate with subsidence of fever. Follow-up after 12 months showed resolution of the lesion. GPA solely presenting as solid mass like lesion in the kidney is extremely rare presentation. Early diagnosis and prompt initiation of the treatment can prevent the progression of the disease.

Bilateral Ureteral Stenosis with Hydronephrosis as First Manifestation of Granulomatosis with Polyangiitis (Wegener's Granulomatosis): A Case Report and Review of the Literature

Ureteral stenosis is a rare manifestation of granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis). We report the case of a 76-year-old woman with progressive renal failure in which bilateral hydronephrosis due to ureteral stenosis was the first manifestation of the disease. Our patient also had renal involvement with pauci-immune crescentic glomerulonephritis associated with high titers of anti-proteinase 3 c-ANCAs, but no involvement of the upper or lower respiratory tract. The hydronephrosis and renal function rapidly improved under immunosuppressive therapy with high-dose corticosteroids and intravenous pulse cyclophosphamide. We reviewed the literature and found only ten other reported cases of granulomatosis with polyangiitis/Wegener's granulomatosis and intrinsic ureteral stenosis: in two cases, the presenting clinical manifestation was unilateral hydronephrosis and in only two others was the hydronephrosis bilateral, but this complication developed during a relapse of the disease. This case emphasizes the importance of including ANCA-related vasculitis in the differential diagnosis of unusual cases of unilateral or bilateral ureteral stenosis.

Renal transplantation in anti-neutrophil cytoplasmic antibody vasculitis

INTRODUCTION

Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) has the propensity to acquire a devastating disease course. Despite the advances in therapeutics, a significant proportion of patients progress to end-stage renal disease (ESRD). Renal transplantation is being increasingly employed in this population, with gradual improvement in outcomes over the years, however, recurrence of disease requires constant surveillance and is associated with graft failure. Areas covered: A structured literature search in PubMed and Medline and abstracts of international conferences was performed to identify cases and cohorts of AAV patients who had undergone renal transplantation for ESRD. The primary objective was to describe the long-term allograft and patient survival and to reflect on current trends in transplantation in AAV and provide recommendations for the phases of pre- and post-transplantation. Expert commentary: Renal transplantation is the treatment of choice for AAV patients with ESRD. The risk of relapse is low with modern immunosuppressive regimes employing mycophenolate mofetil and tacrolimus. It is recommended that the vasculitis be in clinical remission for 12 months prior to transplantation. Although ANCA positivity is not a contraindication for renal transplantation, these patients should be monitored closely for vasculitis relapse post-transplant.

Renal involvement in anti-neutrophil cytoplasmic autoantibody associated vasculitis

Renal involvement is a common and often severe complication of anti-neutrophil cytoplasmic autoantibody (ANCA) associated vasculitides (AAV). With the exception of Churg-Strauss syndrome (CSS), where kidney involvement is not a prominent feature, renal disease is present in about 70% of patients with Wegener's granulomatosis, now called granulomatosis with polyangiitis (GPA) and in almost 100% of patients with microscopic polyangiitis (MPA). Kidney involvement is generally characterized by a pauci-immune necrotizing and crescentic glomerulonephritis with a very rapid decline of renal function (rapidly progressive glomerulonephritis). Even though there are not qualitative differences in glomerular lesions in patients with GPA or with MPA, chronic damage is significantly higher in MPA (and/or P-ANCA positive patients) than in GPA (and/or C-ANCA positive patients). If untreated necrotizing and crescentic glomerulonephritis has an unfavorable course leading in a few weeks or months to end stage renal disease. Serum creatinine at diagnosis, sclerotic lesions and the number of normal glomeruli at kidney biopsy are the best predictors of renal outcome. Corticosteroids and cyclophosphamide (with the addition of plasma exchange in the most severe cases) are the cornerstone of induction treatment of ANCA-associated renal vasculitis, followed by azathioprine for maintenance. Rituximab is as effective as cyclophosphamide in inducing remission in AAV and probably superior to cyclophosphamide in patients with severe flare, and could be preferred in younger patients in order to preserve fertility and in patients with serious relapses.

Urogenital manifestations in Wegener granulomatosis: a study of 11 cases and review of the literature

We describe the main characteristics and treatment of urogenital manifestations in patients with Wegener granulomatosis (WG). We conducted a retrospective review of the charts of 11 patients with WG. All patients were men, and their median age at WG diagnosis was 53 years (range, 21-70 yr). Urogenital involvement was present at onset of WG in 9 cases (81%), it was the first clinical evidence of WG in 2 cases (18%), and was a symptom of WG relapse in 6 cases (54%). Symptomatic urogenital involvement included prostatitis (n = 4) (with suspicion of an abscess in 1 case), orchitis (n = 4), epididymitis (n = 1), a renal pseudotumor (n = 2), ureteral stenosis (n = 1), and penile ulceration (n = 1). Urogenital symptoms rapidly resolved after therapy with glucocorticoids and immunosuppressive agents. Several patients underwent a surgical procedure, either at the time of diagnosis (n = 3) (consisting of an open nephrectomy and radical prostatectomy for suspicion of carcinoma, suprapubic cystostomy for acute urinary retention), or during follow-up (n = 3) (consisting of ureteral double J stents for ureteral stenosis, and prostate transurethral resection because of dysuria). After a mean follow-up of 56 months, urogenital relapse occurred in 4 patients (36%). Urogenital involvement can be the first clinical evidence of WG. Some presentations, such as a renal or prostate mass that mimics cancer or an abscess, should be assessed to avoid unnecessary radical surgery. Urogenital symptoms can be promptly resolved with glucocorticoids and immunosuppressive agents. However, surgical procedures, such as prostatic transurethral resection, may be mandatory in patients with persistent symptoms.

Wegener's granulomatosis: a rare cause of hydronephrosis

A seventy-one-year-old woman was hospitalized at our institution for a right-sided “renal colic” associated with an infectious background. Alithiasic ureterohydronephrosis was diagnosed by imaging. A urinary diversion was thus performed using a double J endoureteral stent. The etiologic assessment of the hydronephrosis showed the presence of a periureteral mass that caused extrinsic ureteral compression. After surgical excision of the ureteral lesion, the Wegener's granulomatosis diagnosis was established. This report is the clinical description of a case of “atypical” Wegener's granulomatosis revealed by the onset of a ureteral disease mimicking a neoplastic process.

Diagnostic approach to ANCA-associated vasculitides

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) include Wegener's granulomatosis, microscopic polyangiitis, and Churg-Strauss syndrome. Given their rarity, protean clinical manifestations, imperfect diagnostic tests, and wide differential diagnosis, they pose a diagnostic challenge even to experienced clinicians. This article describes diagnostic approaches for patients suspected of having one of the ANCA-associated vasculitides. The clinical findings at presentation, the role of laboratory and imaging tests, and the importance of tissue diagnosis are presented. In each section, issues relevant to the differential diagnosis of AAV are discussed.

Successful induction of remission with rituximab for relapse of ANCA-associated vasculitis post-kidney transplant: report of two cases

Kidney transplantation should be considered the treatment of choice for patients with end-stage renal disease due to antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV). However, relapses of AAV have been reported to occur in 9-40% of cases following kidney transplantation and may adversely affect allograft outcome. These relapses are usually treated with cyclophosphamide (CYC) and glucocorticoids, but the repeated use of CYC carries a risk of substantial toxicity that may limit or prohibit its use in some patients. B lymphocytes have been implicated in the pathogenesis of AAV, and their depletion has been effective as salvage therapy for refractory disease in the nontransplant setting. We report the successful induction of remission using rituximab in two patients who suffered relapse of AAV post-kidney transplant. Given the substantial morbidity and adverse effects of CYC, rituximab appears to be a suitable alternative agent to treat relapses of AAV posttransplantation.

Renal transplantation in the ANCA-associated vasculitides

Despite advances in the diagnosis and treatment of the antineutrophil cytoplasmic autoantibodies (ANCA)-associated vasculitides, renal morbidity is common. End-stage renal disease occurs in up to 20% of patients with these diagnoses, which include Wegener's granulomatosis and microscopic polyangiitis. As the mortality of patients with ANCA-associated vasculitis continues to improve, our ability to address the consequences of renal failure in this patient population becomes paramount. Renal transplantation is an important therapeutic option for these patients. Graft and patient survival rates among patients with ANCA-associated vasculitis are comparable to those observed in nondiabetic patients. This review summarizes our current knowledge of indications and contraindications for renal transplantation in these patients, the recurrence of vasculitis after transplantation and the impact of posttransplant immunosuppression on the clinical course of these patients.

[Ureteral stenosis in Wegener's granulomatosis. Case report]

INTRODUCTION

Ureteral stenoses in Wegener's granulomatosis are rare. They usually involve the pelvic portion of the ureter and are caused by vasculitic lesions or granulomatous inflammation.

CASE

A 38-year-old woman with Wegener's granulomatosis was treated with corticosteroids and monthly intravenous cyclophosphamide pulses. After 4 months, urinary retention developed, accompanied by lumbar pain, associated with protenuria and hematuria, and related to bilateral ureteral stenoses. Treatment by endoscopic dilatation and double J stents led to with clinical and radiological improvement, while the medical treatment continued.

CONCLUSION

Hematuria in patients with Wegener's granulomatosis suggests renal involvement, but ureteral stenoses must also be considered when these patients present hematuria or urinary tract infections. Surgery should be reserved for those patients in whom medical treatment is not rapidly effective.

Papillary necrosis causing hydronephrosis in renal allograft treated by percutaneous retrieval of sloughed papilla

Obstructive uropathy is the second most common urological complication in a transplanted kidney. The usual causes of obstruction are ureteral stenosis and calculi. Papillary necrosis as a cause of obstruction in a transplant kidney is extremely rare with only one prior report published. Moreover, percutaneous removal of sloughed papilla in a transplant kidney has not previously been reported. We report an unusual case of a sloughed papilla causing hydronephrosis of a transplant kidney and its successful percutaneous removal. The recognition of renal papillary necrosis is important, not only because it can be a sign of acute rejection but also it because it can lead to obstruction, infection and potentially the loss of the transplant as exemplified by our case. Rapid diagnosis and meticulous retrieval technique are the crucial factors in minimizing the complications due to obstruction of a transplanted kidney by sloughed papilla.

Ureteral stenosis as the sole manifestation of Wegener's granulomatosis

In Wegener's granulomatosis, necrotizing lesions are typically located in the upper and lower respiratory tract and kidneys, and ureteral involvement is uncommon. We report 2 cases in which intrinsic ureteral stenosis was the sole manifestation of this small-vessel vasculitis. Excisional surgery evidenced characteristic granulomatous inflammation that allowed adjuvant elective medical treatment. Urologists, nephrologists, and internists should be aware of this atypical presentation of Wegener's granulomatosis. Thorough clinical and biologic assessments are warranted in the initial workup of isolated intrinsic ureteral stenosis.

Recurrent ANCA-associated small vessel vasculitis after transplantation: A pooled analysis

BACKGROUND

Recurrent antineutrophil cytoplasmic antibody (ANCA)-associated small vessel vasculitis (ANCA-SVV) after renal transplantation has been described in case series. However, general information regarding the frequency, character, and predictors of recurrent disease after transplantation is currently lacking. We considered the rate of relapse, whether a positive ANCA at the time of transplantation predicted relapse, and whether cyclosporine A prevented recurrent disease.

METHODS

We performed a pooled analysis of published data, added to the experience at the Universities of North Carolina (14 patients) and Lund, Sweden (11 patients). To avoid reporting bias, only case series were included for analysis. Subgroup analysis was performed by disease category (Wegener's granulomatosis, microscopic polyangiitis, or necrotizing crescentic glomerulonephritis) and ANCA staining pattern.

RESULTS

ANCA-SVV recurred in 17.3% of all patients (N = 127), in 20% of cyclosporine A-treated patients (N = 85), and in 25.6% of patients with circulating ANCA at the time of transplantation (N = 39). There was no statistically significant difference in the relapse rate between patients treated and those not treated with cyclosporine A (P = 0.45), between those with and without circulating ANCA at the time of transplant (P = 0.75), or between patients with Wegener's granulomatosis and those with microscopic polyangiitis or necrotizing crescentic glomerulonephritis alone (P = 0.62).

CONCLUSION

There is a substantial relapse rate in the ANCA-SVV population. Therapy with cyclosporine A does not protect against recurrent ANCA-SVV, and the presence of a positive ANCA at the time of transplantation does not preclude transplantation. These conclusions must be substantiated with a prospective study of renal transplantation in patients with ANCA-SVV so as to optimize their management.