Successful treatment of spontaneous kidney graft decapsulation 18 years after renal transplantation: a case report

Table 1. Cases of adrenal insufficiency in haemodialysis patients Case 52 y/o F 54 y/o F 44 y/o F 33 y/o M 36 y/o F Type Primary Panhypo-pituitarrism, primary Isolated ACTH deficiency Primary Primary Cause Tuberculosis Amyloidosis Unknown Steroid withdrawal Steroid withdrawal Clinical findings Hyper-pigmentation Fever Fever Fever Fever Treatment PSL 10 mg/day Cortisone acetate 37.5 mg/day Without glucocorticoid mPSL 30 mg/day mPSL 20 mg/day supplementation HPA axis ACTH very high ACTH not measured ACTH very low ACTH not measured ACTH not measured Ref. Fig. 1. Time course of stimulation tests to evaluate the HPA axis. Blood levels of aldosterone (᭡-᭡), cortisol (•-•) and ACTH (᭿-᭿) shown, as well as described in the text, were measured at the Health Sciences Research Institute, Yokohama, Japan. Open circles in (e) (•-•) indicate blood glucose levels. Values under a horizontal axis of each figure indicate minutes elapsed. Informed consent was obtained for each test performed. Sir, The detection of a perirenal fluid collection causing graft dysfunctions is common in the early postoperative phase after renal transplantation. These are typically lymphoce-les, urinomas, abscesses and haematomas, and treatment is well established. Perirenal fluid collection causing acute or sub-acute renal failure several years after engraftment is unusual. A rare, but potentially treatable condition is acute spontaneous decapsulation of the kidney graft. We hereby present a case of spontaneous decapsulation and rapid decline of renal function 18 years after engraftment. A 41-year-old Caucasian male with end-stage renal failure was diagnosed in 1989 with chronic glomerulonephri-tis (not biopsy verified) and received a renal transplant in 1990 at age 23, from his HLA-identical 21-year-old brother (CMV+ to +, PRA−). There were no rejections or other early complications. Graft function remained steady over the next 18 years with s-creatinine 100–120 µmol/L. Im-munosuppression consisted of CsA (125 mg b.i.d., C 0 target level 75–125), prednisolone (5 mg × 1/day) and azathio-prine (75 mg/day, 6-TGN target 100). In 2003, an ultrasound of the renal graft and in 2005 a CT scan of the abdomen was done with normal findings regarding the graft. During a routine control at the local hospital s-creatinine had increased from a stable value (100–120 µmol/L) to 150 µmol/L. The development of chronic allograft nephropathy was suspected. Azathioprine was replaced by mycophenolate mofetil (MMF; 750 mg b.i.d.), and an ultrasound-guided renal biopsy was planned. The day after switch from azathioprine to MMF, the patient experienced a sudden onset of …