Skip to Main Content

++

INTRODUCTION

++

CASE LEARNING OBJECTIVES

  • Identify signs and symptoms of cytomegalovirus (CMV) infection for renal transplant recipients post rejection

  • Develop a comprehensive treatment plan for renal transplant recipients with CMV infection

  • Determine the appropriate duration of treatment and appropriate dose for CMV infection

  • Formulate a medication counseling plan for a renal transplant recipient

++

PATIENT PRESENTATION

++

Chief Complaint

++

"I'm just here for a my regular checkup"

++

History of Present Illness

++

Karen Smith is a 35-year-old African American female with a history of end stage renal disease (ESRD) secondary to hypertension (HTN) and type 2 diabetes mellitus. She underwent a 4 antigen mismatched deceased donor kidney transplant 11 months ago. This was her second transplant. Prior to her second transplant, she was on peritoneal dialysis 5 times a week for 1 year. She received blood transfusions due to anemia on two occasions while she was on dialysis as well as had two prior pregnancies. Pre-transplant testing revealed a peak cytotoxic PRA of 44% and current cytotoxic PRA of 20%. She received induction with rabbit anti-thymocyte globulin (rATG) and a rapid steroid taper. Pre-transplant viral serologies showed that Ms. Smith was cytomegalovirus (CMV) IgG negative and the donor was CMV IgG positive. Maintenance immunosuppression includes tacrolimus and mycophenolate mofetil. She was on sulfamethoxazole/trimethoprim for 6 months and nystatin for 2 months for infectious prophylaxis. She was prescribed valganciclovir for 6 months post-transplant; however, she reported missing "a couple of weeks" of this medication due to issues with insurance co-pays. Post-transplant, her serum creatinine nadir was 1.1 mg/dL (97 μmol/L) and has remained relatively constant. However, 7 months post-transplant, she had an elevation in her serum creatinine (2.5mg/dL [221 μmol/L]) and a biopsy was obtained. Her biopsy revealed a grade 1B acute cellular rejection. She was treated with a course of 4 doses of rATG and a steroid pulse (500 mg × 3 doses) followed by a rapid taper for 7 days. She was last seen in the renal transplant clinic 3 weeks prior. She states that she has been feeling tired and has had constant diarrhea and abdominal pain for the past 2 weeks. She was not sure if it was from something that she had eaten or if she caught a virus. She has also noticed a slight decrease in her urine output, which she attributes to not drinking enough water and dehydration from the weather humidity.

++

Past Medical History

++

ESRD s/p deceased donor kidney transplant in 2011 (rATG induction × 4 doses)

++

Acute cellular rejection in 2012 (treated with rATG and steroid pulse)

++

Hypertension × 10 years

++

Diabetes mellitus type 2 × 8 years

++

Hyperlipidemia × 6 years

++

Diabetic gastroparesis

++

Past Surgical History

++

S/p living donor kidney transplant ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.