Adenovirus-Associated Thrombotic Microangiopathy and Necrotizing Interstitial Nephritis in a Renal Transplant Recipient: A Case Report and Review

Adenovirus nephritis in adult kidney allograft recipients: a systematic review of literature

BACKGROUND

Adenovirus nephritis is an increasingly recognized complication in adult kidney transplant recipients, characterized by its diverse clinical presentations and diagnostic challenges. This systematic review summarises the clinical profiles and outcomes of adenoviral nephritis in kidney allograft recipients.

METHODS

We conducted a systematic search of PubMed, Embase, and Web of Science for studies (case reports or series) with individual patient data on adult kidney transplant recipients with confirmed or presumptive adenoviral nephritis up to October 2, 2024. Clinical profile, treatment and outcome data with adenoviral nephritis were collected and summarised for all patients. We compared features of early and late adenoviral nephritis (diagnosis before and after 90 days post-transplantation).

RESULTS

Thirty-nine studies met inclusion criteria, involving 57 patients with a mean age of 45.7 years and a male predominance. The median time to infection post-transplant was 168 days. The most common symptoms were fever (68.5%), dysuria (49%) and diarrhoea (21%). Early adenoviral infection was more common in cadaveric graft recipients. Fever and gross haematuria were more common in late adenoviral infections. Biopsies showed interstitial nephritis (100%), with some having acute tubular necrosis (53%). Granulomas were seen in 61.2%. Glomeruli and peritubular capillaries were not affected in any of the biopsies. Reversible graft dysfunction was observed in 75% of cases, while mortality was noted in three patients.

CONCLUSION

Adenoviral nephritis is associated with diverse clinical manifestations with differing chronology post-transplantation. Graft dysfunction is associated with reversible interstitial nephritis. Further research is necessary to improve outcomes.

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.

Case report: An unusual case of multisite embolism in a patient with adenovirus pneumoniae

A 36-year-old previous healthy man presented with fever, cough, and dyspnea associated with adenovirus pneumonia. The patient developed left ventricular thrombus, pulmonary embolism and multisite embolism of undetermined etiology. Adenovirus is a rare cause of thrombotic events in immunocompetent individuals, calling for further studies for early diagnosis and management.