Introduction:
Graft Versus Host Disease (GVHD) is the consequence of an immunologic reaction of engrafted lymphoid cells against the tissues of the host. GVHD is mainly associated with hematopoietic stem cell transplantation, and it occurs much less frequently after liver and small intestine transplantation. There are very few case reports of occurrence of GVHD post renal transplantation. Here is our report.
Methods:
A 34 year old male, underwent live related ABO compatible haplomatch renal transplant, 5 years ago, with his mother being the donor. He had good graft function until 2 years ago, when he developed nephrotic range proteinuria with graft dysfunction (S.creatinine-2mg/dl). Graft biopsy was suggestive of IgA Nephropathy with moderate interstitial fibrosis and tubular atrophy (IFTA). He was managed conservatively with optimization of immunosuppression and blood pressure control, but there was progressive decline in graft function (serum creatinine- 5mg/dl by May 2024).
2months ago, he presented with fever, acute onset abdominal pain, abdominal distension and reduced urine output. He was diagnosed with Dengue fever with Acute Pancreatitis and was conservatively managed. Subsequently he had diarrhea and abdominal discomfort for a few days which was managed with antibiotics. The immunosuppression was optimized and he improved.
Within few days, he presented again with severe pain abdomen and abdominal distension. He was tachypnoeic, restless and was in shock. He had severe anaemia (Hb-4g/dl). CECT abdomen showed severe necrotizing pancreatitis, hematoma in the left lumbar region, with moderate hemoperitoneum. He received multiple blood transfusions and underwent emergency coil embolization of the splenic artery. Tacrolimus and Mycophenolate mofetil were withheld and broad spectrum antibiotics were started. He then developed Obstructive jaundice. CT abdomen did not reveal any obstructive pathology. He was planned for Endoscopic Retrograde Cholangiopancreatography (ERCP) and stenting of the pancreatic duct, meanwhile he developed severe respiratory failure (ARDS) and had to be intubated and mechanically ventilated. He was initiated on Continuous Renal Replacement Therapy (CVVHDF), and was started on higher broad spectrum antibiotics and antifungal agents to cover for sepsis. A liver biopsy was planned, but was withheld as he had severe thrombocytopenia and coagulation abnormalities. He had elevated D-dimer levels and was diagnosed with DIC. He had progressive abdominal distension and 2 Litres of hemoperitoneum was drained. He received multiple blood transfusions including Fresh Frozen Plasma and Cryoprecipitate. He developed painful eruptions over the buttocks, thighs and back. The skin biopsy was suggestive of Graft versus Host Disease. He received pulse methylprednisolone for 3 days and planned for Intravenous Immunoglobulin (IVIg). Meanwhile, patient’s clinical condition gradually deteriorated and he became comatose. CT brain showed massive intracranial haemorrhage with midline shift and he subsequently succumbed to his illness.
Results:
Conclusions:
This is a very rare case of GVHD occurring several years post renal transplant. This could have been probably triggered off by Dengue Viral Infection. The mortality after GVHD post kidney transplantation is very high. This case has been presented here to raise awareness about the illness. Further research is needed to develop effective methods for its prevention and its treatment.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.