A 46-year-old African American woman with a history of lupus nephritis, kidney transplant, and immunosuppression was admitted with elevated creatinine levels. She had been hospitalized previously for C. difficile colitis and CMV viremia, which caused acute kidney injury. Her creatinine remained elevated upon discharge and during follow up visits, leading to her current admission to evaluate ongoing kidney dysfunction.

1. John
R.
Martinelli,
MSIII
SGUSOM
Case
#2:
History
12/16/13
Identifying
Information
Ms.
K.A.
is
a
pleasant
46-­‐year-­‐old
African-­‐American
lady
who
was
admitted
to
the
SBMC
transplant
nephrology
service
on
December
11,
2013.
Chief
Complaint
Elevation
of
serum
creatinine
level
noted
on
recent
outpatient
clinic
visits.
History
of
Present
Illness
Ms.
K.A.’s
history
includes
acute
kidney
injury
(AKI),
clostridium
difficile
colitis,
cytomegalovirus
(CMV)
viremia,
pancytopenia
secondary
to
therapeutic
immunosuppression,
living
unrelated
renal
transplant
(LURT),
pulmonary
embolism
(PE),
end
stage
renal
disease
(ESRD),
as
well
as
systemic
lupus
erythematosus
(SLE).
On
October
24,
2013,
Ms.
K.A.
presented
to
the
SBMC
ED
with
complaints
of
persistent
diarrhea
over
a
two-­‐week
period
combined
with
right
lower
abdominal
discomfort,
low-­‐grade
fever,
and
malaise.
She
was
admitted
on
this
visit
with
subsequent
laboratory
investigations
finding
evidence
of
stool-­‐positive
toxin
for
c.
difficile
colitis
concurrent
with
PCR+
CMV
viremia.
Blood
and
urine
cultures
were
negative.
She
had
no
dysuria,
hematuria,
urgency,
or
frequency.
Of
possible
significance
preceding
this
episode
was
a
dental
visit
in
which
she
was
prescribed
an
antibiotic,
perhaps
precipitating
the
c.
difficile
colitis.
With
respect
to
her
renal
status,
serum
creatinine
was
found
to
peak
at
4.4
(baseline
1.2),
suggesting
associated
secondary
acute
kidney
injury
(AKI).
Renal
biopsy
was
non-­‐specific
but
revealed
diffuse
severe
tubular
injury,
interstitial
eosinophilia,
mesangial/basement
membrane
deposits,
as
well
as
focal
segmental
glomerulosclerosis
(FSGS).
There
was
no
evidence
of
rejection.
Understanding
Ms.
K.A.
is
s/p
LURT
(2010),
and
given
her
lifetime
immunosuppressive
status,
this
episode
exemplifies
her
susceptibility
for
opportunistic
infection.
Therefore,
her
myfortic
(mycophenolic
acid)
was
discontinued.
IV
gancyclovir
in
addition
to
oral
vancomycin
was
added
over
a
period
of
six
days
leading
to
improvement
as
evident
by
negative
repeat
PCR,
stool
samples,
decreased
diarrhea,
and
decreased
abdominal
pain.
However,
her
creatinine
level
remained
elevated
(4.5)
further
supporting
associated
and
possibly
refractory
AKI.
She
was
discharged
October
30,
2013
on
both
oral
valgancyclovir
and
oral
metronidazole
in
addition
to
her
long-­‐standing
therapy,
with
close
outpatient
monitoring
of
her
renal
status.
She
has
been
compliant
with
her
current
treatment
and
scheduled
outpatient
visits.
Nonetheless,
Ms.
K.A.’s
creatinine
levels

2. have
failed
to
return
to
baseline
with
fluctuations
between
2
–
4
found
during
her
recent
outpatient
visits,
which
is
the
indication
for
her
current
admission.
At
this
time,
Ms.
K.A.
continues
to
be
asymptomatic
with
respect
to
dysuria,
hematuria,
urgency,
frequency,
and
she
no
longer
notices
abdominal
pain
or
tenderness.
As
instructed
per
her
last
hospitalization,
she
discontinued
metronidazole
but
has
continued
oral
valgancyclovir.
Urinalysis
was
negative
but
showed
slight
pyuria,
therefore,
urine
cultures
are
pending.
Repeat
CMV
PCR
is
also
pending
to
rule-­‐out
persistent
viremia.
Her
creatinine
is
3.5
(baseline
1.2)
while
awaiting
repeat
renal
biopsy
results.
The
possibility
of
re-­‐starting
myfortic
in
the
event
of
biopsy
proven
recurrent
SLE
nephritis
(vs.
active
viremia)
will
be
considered.
Of
course,
allograft
rejection
must
again
be
ruled-­‐out.
Lab
results
on
this
admission
show
anemia
and
pancytopenia
consistent
with
renal
dysfunction
and
therapeutic
immunosuppression.
However,
interestingly
her
CBC
hemoglobin
dropped
suspiciously
post-­‐biopsy
(9.5
-­‐>
8.9)
which
will
be
re-­‐evaluated
in
24
hours
to
rule-­‐out
possible
blood
loss
or
hematoma
during
biopsy.
In
October
2010,
Ms.
K.A.
received
a
successful
LURT
due
to
ESRD
as
a
consequence
of
SLE
nephritis.
She
tolerated
the
allograft
well
without
evidence
of
rejection
and
with
appropriate
renal
function,
represented
by
a
subsequent
baseline
creatinine
of
1.2.
Of
note,
during
her
inpatient
stay
prior
to
surgery
she
developed
a
pulmonary
embolism,
which
was
successfully
managed
with
heparin.
Subsequent
labs/imaging
were
negative
for
a
pre-­‐disposing
coagulopathy
or
deep
venous
thrombosis
(DVT).
Her
post-­‐allograft
course
had
been
uneventful
until
her
hospitalization
several
weeks
ago
in
October
2013.
Ms.
K.A.
was
first
diagnosed
with
SLE
in
1998;
however,
she
has
not
experienced
additional
systemic
manifestations
of
her
disease
other
than
renal
involvement.
In
early
2010,
she
was
placed
on
peritoneal
dialysis
(PD)
followed
by
a
course
of
hemodialysis
(HD)
prior
to
her
allograft.
Past
Medical
History
Chronic/Active
1. LURT
(2010)
with
unspecified
acute
renal
injury
(2013)
Myfortic
(mycophenolic
acid)
discontinued
Prograf
(tacrolimus)
Prednisone
Valcyte
(valgancyclovir)
prophylaxis
Calcium
carbonate
2. Systemic
Lupus
Erythematosus
(1998)
Prednisone

3. Acute/Resolved
1. Cytomegalovirus
(CMV)
viremia,
resolved
(2013)
2. C.
difficile
colitis,
resolved
(2013)
3. Pulmonary
embolism,
resolved
(2010)
Past
Surgical
History
Successful
living
unrelated
renal
transplant
(LURT)
in
2010.
Medication
Prograf
(tacrolimus)
4mg
PO
QD,
5mg
PO
HS
Prednisone
5mg
PO
QD
Valcyte
(valgancyclovir)
450mg
PO
QD
x
every
2
days
Calcium
carbonate
500mg
PO
TID
w/meals
Allergies
Tetracyclines
Social
History
Ms.
K.A.
is
a
pediatric
physical
therapist
and
currently
employed
full
time.
Other
than
time
absent
from
work
due
to
recent
hospitalizations,
she
does
not
believe
her
condition
has
interfered
with
her
daily
duties
or
activities.
She
tries
to
maintain
a
balanced
diet
and
denies
smoking,
alcohol,
or
illicit
drug
use.
Family
History
Father:
Unremarkable
Mother:
Unremarkable
Review
of
Systems
Constitutional:
No
fever,
No
chills,
No
fatigue.
Eye:
No
symptoms
of
dry
eye,
keratitis,
episcleritis,
uveitis.
Ear/Nose/Mouth/Throat:
No
nasal
congestion,
No
sore
throat.
Respiratory:
No
shortness
of
breath,
No
cough,
No
wheezing.
Cardiovascular:
No
chest
pain,
No
palpitations.
Genitourinary:
No
dysuria.
Hematology/Lymphatics:
History
of
PE
in
2010.
Endocrine:
No
excessive
thirst.
Immunologic:
Lifetime
therapeutic
immunosuppression.
Musculoskeletal:
No
joint
pain,
No
muscle
pain.
Integumentary:
No
malar
rash.

4. Neurologic:
Psychiatric:
Alert
and
oriented
x
4.
No
depression,
Not
suicidal,
Not
delusional,
No
halluc.