A puzzling case of high serum creatinine in a healthy woman.

kidney disease who started peritoneal dialysis in 2000. Four years later, the patient received a cadaver donor transplant from a 52-year-old woman. Surgery was performed without technical difficulties and good initial graft perfusion was observed. An immunosuppressive regimen consisting of tacrolimus, mycophenolate mofetil and steroids was initiated. The post-operative course showed persistent anuria with dependency on dialysis every 48 h. Isotopic renogram demonstrated a vascular pattern with an almost flat excretion curve. Renal biopsy showed broad ischaemic necrosis of the tissue sample. Detailed screening for thrombosis risk factors revealed increased prothrombin immunoreactivity and molecular genetic analysis identified a heterozygous point mutation at position 20210 of the prothrombin gene. Recently, a clinical study reported the potential for inherited hypercoagulability due to the V Leiden factor or prothrombin G20210A, to predispose to acute graft thrombosis [1]. The G20210A prothrombin mutation occurs in 1–2% of the population and represents a frequent cause of inherited thrombophilia. Our patient developed RCN in the early post-transplant period. Organ transport, storage and transplantation problems and haemodynamic instability or rejection in the early post-transplant period were ruled out. Only the G20210A mutation of the prothrombin gene was found. The G20210A prothrombin mutation is a risk factor for graft loss and is linked to a high frequency of acute vascular rejection due to the broad antigen exposure triggered by vascular wall injury and induced by the prothrombotic state [1,2]. The first case series of patients heterozygous for the G20210A prothrombin mutation and unsuccessful kidney transplantation was published in 1999 and included three renal transplant recipients who experienced graft loss due to thrombosis in the peri-operative period [3]. The G20210A mutation is also associated with a 2.95-fold increased risk for allograft loss, an observation that provides the basis for screening recipients before renal transplantation [4]. In contrast, screening of 562 transplant recipients found a prevalence of 2% and no significant differences were reported in the 30 day and 1 year graft survival rates among patients with or without the G20210A mutation [5]. It seems reasonable to believe that endothelial injury and ischaemic-reperfusion syndrome were related to transplantation in a woman with no previous history of thrombophilia, but with a heterozygous point mutation at position 20210 of the prothrombin gene, could trigger RCN. New research is required to elucidate the role of this mutation in the course of kidney transplantation.