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
"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.
ESRD s/p deceased donor kidney transplant in 2011 (rATG induction × 4 doses)
Acute cellular rejection in 2012 (treated with rATG and steroid pulse)
Diabetes mellitus type 2 × 8 years
S/p living donor kidney transplant ...