Tue28September1157AM 8

A 34-year-old woman comes to the Emergency department complaining of worsening nausea and lethargy over the past few weeks. She received a kidney transplant for type 1 diabetes-related end stage renal failure some nine months earlier.

Although she has attended for routine blood tests, she has not made any clinic appointments over the past two months. Of note on previous sampling is a ciclosporin level slightly below the therapeutic range, and a progressive rise in creatinine from 162 µmol/L post transplant, to 232 µmol/L four weeks earlier.

Examination reveals a BP of 152/85 mmHg, pulse is 85 and regular. She is not in fluid overload.

Investigations reveal:

Hb 105 g/L (115-160)

WCC 5.3 ×109/L (4-10)

PLT 220 ×109/L (130-400)

Na 138 mmol/L (135-145)

K 5.9 mmol/L (3.5-5.5)

Cr 302 µmol/L (70-120)

CRP 8 (<10)

ECG Normal sinus rhythm

Urine Protein 1+

Which of the following is the most likely diagnosis?

(Please select 1 option)

Diabetic nephropathy

Acute rejection Incorrect answer selected

Ciclosporin toxicity

Hypertensive nephropathy

Chronic rejection This is the correct answer

Explanation

Chronic rejection develops months to years after transplant and is characterised by both cell-mediated and antibody-mediated immune attack. It manifests clinically by progressive fibrosis and a slow rise in serum creatinine. The risk of chronic rejection is increased with inadequate immunosuppression, and where there is an autoimmune pathology underlying the renal failure, (for example, type 1 diabetes). Increased immunosuppression may slow the rise in creatinine, but once fibrosis has initiated it is usually progressive.

Acute rejection is seen in the first six months after transplant, and is usually related to a T cell response against donor antigens. A lymphocytoxicity assay is performed pre-transplant in an attempt to minimise acute rejection.

Ciclosporin toxicity is unlikely given that this patient's levels are low normal.

Hypertensive and diabetic retinopathy would take many years to develop in the transplanted kidney.

Answer Statistics

1

2%

2

15%

3

13%

4

3%

5

69%

Times answered: 258