신장내과 R3 김경엽 Case Conference

김 0 화 (F/46) 입원 2006 년 7 월 23 일 CC: for KTP PI: 1988 년 nephrotic syndrome 있었으나 renal biopsy 시 행하지 않고 지내다가 CRF 발생하여 1998 년부터 AVF 통 해 hemodialysis 시행받으며 특별한 문제 없이 지내던 환 자로 cadaveric donor 로부터 KTP 시행 받기 위해 입원. PMHx: DM / Hypertension / hepatitis / TB (-/-/-/-) Op Hx (+) AVF op 1998 PHx: alcohol(-) smoking(-)

Review of system Weight loss (-), fever (-), chill (-), fatigue (-) Cough(-), sputum (-), hemoptysis (-), dyspnea (-) Chest pain (-), palpitation (-), chest discomfort (-) A/N/V/D/C (-/-/-/-/-) Oliguria (+)

Physical examination 140/70 mmHg - 96 회 /min - 20 회 /min °C Alert consciousness Mild pale conjunctiva Clear breath sound without crackle Regular heart without murmur Soft and flat abdomen, normoactive bowel sound No hepatosplenomegaly No abdominal tenderness and rebound tenderness No costovertebral angle tenderness No peripheral pitting edema

Laboratory findings CBC/DC 5590/mm g/dL – 32.5 % -150k/mm 3 (Seg: 74%, MCV 91.7 fL, MCH 30.9 pg) aPTT 37.7s (control 33s), INR 1.03 Chemistry T/D bil 0.7/0.1 mg/dL AST/ALT 19/23 U/L T-prot/Alb 6.2/3.5 g/dL ALP/rGT 55/26 U/L BUN/Cr 63/11.5 mg/dL Na/K/Cl 136/5.5/101 mEq/L Glucose 115 mg/dL LD/CK 408/82 U/L Ca /P /uric acid 9.8/8.9/6.8 mg/dL TIBC/iron 208/22 µg/dL Ferritin 151 ng/mL ABGA mmHg mmHg mmol/L SaO2 97.7% (room air)

Tissue typing and immunogenetics Recipient ABO B (+) HLA A 24, 0 / B 44, 48 / DR 7, 9 HLA cross matching (-) Donor (F) Hypertension, pontine hemorrhage ABO B (+) HLA A 24, 0 / B 7, 35 / DR 1, 15 BUN/Cr 18/0.2 mg/dL -> 28/2.4 mg/dL HBsAg (-) / anti-HBs (-) / anti-HBc (-), anti-HCV (-) CMV IgG(+), CMV IgM (-)

Initial assessments #1 ESRD on hemodialysis #2 Anemia due to chronic illness

Initial plans Kidney transplantation from cadaveric unrelated donor Immunosuppressive treatment (basiliximab, steroid, tacrolimus, mycophenolate mofetil)

Clinical course 날짜 Urine output (mL/day) BUN/Cr (mg/dL) Tacrolimu s Level (ng/mL) HD 7/ /11.5 7/ / HD 7/ / / /5.2HD 7/ / HD Renal doppler & scan Renal biopsy Ventilator

Renal doppler & scan (POD1) TPK at LLQ abdomen 10.9 x 5.6 x 5.5 cm TPK 의 blood flow 가 전반적으로 감소 Main renal artery 의 end-diastolic flow 소실 Mean RI = 0.85 Markedly decreased renal function of TPK : suggestive of severe ATN (Tc-99m MAG3)

Renal biopsy (POD2)

Capillary dilatations, filled with red blood cells Neutrophils and plateles with fibrin thrombi Global sclerosis (3/6) Tubules: partial epithelial necrosis with little tubulitis Interstitium: patchy mononuclear, neutrophilic infiltrations Peritubular capillaries: collection of neutrophils and fibrin thrombi Acute humoral rejection, consistent with IF findings: A(+)(3/3) Diffuse granular mesangial deposits C3(+)(3/3) Diffuse granular mesangial deposits

Chest PA (POD1, POD5)

Clinical course 날짜 Urine output (mL/day) BUN/Cr (mg/dL) Tacrolimu s Level (ng/mL) HD 7/ /11.5 7/ / HD 7/ / / /5.2HD 7/ / HD Renal doppler & scan Renal biopsy Ventilator

Bronchoalveolar lavage (POD8) Fresh bloody sputum -> bronchoalveolar lavage RBC 50000/mm 3, WBC 9700/mm 3 (neutrophil 95%) Culture (-) TB PCR (-), AFB stain (-) PCP (-) CMV PCR (-), IgG (+), IgM(-) ANA (-), ANCA (-)

Assessments #1 S/P KTP, delayed graft function may be due to ATN R/O humoral rejection R/O calcineurin inhibitor toxicity #2 Alveolar hemorrhage, unknown causes

Plans Stop immunosuppressive treatment If necessary, nephrectomy of KTP Transfer to Dept. of pulmonology for treatment of lung lesions

날짜 Urine output (mL/day) BUN/Cr (mg/dL) Tacrolimus Level (ng/mL) 7/ /11.5 7/ / / / /270040/ /580040/ /830060/ / / / / Renal biopsy CT angiography

Renal biopsy (POD 11)

Diffuse acute ischemic necrosis and two global sclerosis The small viable portion shows similar findings as the previous biopsy Diagnosis : Acute humoral rejection, consistent with (correlated with clinical history) C4d staining (-)

CT angiography(POD21)

Chest AP (POD21, POD28) Sputum culture : pseudomonas, CNS (piperacillin/tazobactam, amikacin, vancomyin)

Assessments #1 S/P KTP, delayed graft function may be due to ATN R/O humoral rejection R/O calcineurin inhibitor toxicity #2 Alveolar hemorrhage, unknown causes #3 Bacterial pneumonia

Brain CT (POD 32)

Chest AP (POD34, POD38)