Adenovirus Insterstitial Nephritis

 

 

Clinical History

 

This 45 year old man has ESKD due to IgA nephropathy. There was stable renal function until 18 months post-transplant. At that point a rise in the serum creatinine from 1.3 to 1.8 mg/dl triggered a biopsy which was interpreted as TCMR Banff grade 1B. There was no response to steroids. C4d stain -ve. No DSA. The biopsy was repeated 3 weeks later.

 

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Diagnosis

 

The diagnosis in this case was ADV interstitial nephritis. It was based on:

  •      - viral cytopathic effect
  •      - presence of viral antigens by immunohistochemistry
  •      - demonstration of 70 nm particles by EM

 

It was further confirmed by a urine culture.

 

Differential Diagnosis of Refractory Acute Rejection

 

The differential diagnosis of therapeutically refractory rejection includes:

 

  •      - Non compliance
  •      - Pharmacokinetic issues (poor absorption, rapid metabolism, drug interaction)
  •      - Steroid resistant T-cell mediated rejection
  •      - Antibody mediated rejection
  •      - Post-transplant lymphoproliferative disease
  •      - Infectious interstitial nephritis

 

Infectious Interstitial Nephritis

 

  •      - Common bacteria (E. coli, Klebsiella, Proteus)
  •      - Unusual bacteria which may not grown on culture. These can present as "sterile pyuria" with WBC in urine sediment. An infectious disease consult may be needed in these cases.
    •           - Examples include: Mycobacteria, Anaerobes, Gardnerella, Ureaplasma, Eikenella, Chylamydia, Mycoplasma
  •      - Fungal infections
  •      - Parasites
  •      - Viral infections

 

Non-Recection Interstitial Nephritis

 

  •      - Drug reactions
  •      - Autoimmune disorders (SLE, MCTD, Sjogren)
  •      - Obstructive uropathy
  •      - Chemical injury (cystinosis, light chain deposition, gout, crystals of 2,8 DHA)
  •      - Interstitial inflammation due to other renal diseases (including glomerulonephritis and arterionephrosclerosis)
  •      - Genetic or metabolic disorders: cystinosis, 2-8 DHA crystal deposition (adenine phospho-ribosyl transferase)

 

Viral Inclusions in the Kidney

 

  •      - Human polyomaviruses (BKV, JCV, SV40)
  •      - Herpesviruses: CMV, HSV, VZV
  •      - Adenovirus

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