Korean J Transplant.  2022 Nov;36(Supple 1):S56. 10.4285/ATW2022.F-1751.

Successful treatment of renal malakoplakia with reduction of immunosuppression and antimicrobial therapy after kidney transplantation: case report

• Yim SH
• Min EK
• Kim HJ
• Lim BJ
• Huh KH

• KMID: 2535260
• DOI: http://doi.org/10.4285/ATW2022.F-1751

Abstract

Malakoplakia is a rare granulomatous disease that usually affects immunocompromised individuals. Genitourinary tract is the most frequent site of infection, manifesting as recurrent urinary tract infection with impaired renal function. Cases of renal al- lograft malakoplakia are generally associated with a poor graft and patient survival. We present the case of renal malakoplakia after kidney transplantation. A 33-year-old female with CKD grade 5 underwent living-donor kidney transplantation from her mother at Severance Hospital. She was administered 375mg/BSA of rituximab of for desensitization due to high PRA (Class 1: 55%). Induction immunosuppression was initiated with 1.5mg/kg of anti-thymoglobulin with intravenous methylprednisolone. Maintenance immunosuppression was done with tacrolimus and oral methylprednisolone with mycophenolate mofetil. She was hospitalized for urinary tract infection with elevated serum creatinine, 3.14 mg/dL seven months after kidney transplanta-tion. Ultrasonography revealed two mass-like lesions on the upper-pole and mid-pole of the transplanted kidney. Renal biopsy was undertaken for further pathological examination and malakoplakia involving renal parenchyma was diagnosed. Upon the diagnosis, immunosuppression was reduced and mycophenolate mofetil was stopped. The dose of tacrolimus was reduced to achieve the trough levels of 3–5 ng/mL. Fluoroquinolone was used for 16 days and TMP/SMX dose was doubled for 7 days. Follow-up renal biopsy was performed 10 days after the initial renal biopsy. Acute T-cell mediated rejection (Banff IA) was di-agnosed in addition to malakoplakia. Methylprednisolone pulse therapy was promptly performed to treat the acute TCMR. Her hospitalization lasted for 3 weeks and she was closely observed during her outpatient clinic visit. The mass-like lesions disap-peared on ultrasonography after five months and the renal function has been improved. The serum creatinine level decreased to 1.29 mg/dL eight months after the diagnosis of malakoplakia. Our results suggest that a successful treatment of renal mala-koplakia can be achieved with reduction of immunosuppression and sustained antimicrobial therapy.