Adenovirus in a Kidney Transplant Recipient

A kidney transplant recipient in his 30s with kidney failure secondary to IgA nephropathy presented to clinic with gross hematuria. He received a deceased donor kidney transplant 16 months prior from a donor in their 20s. He received basiliximab for induction and experienced immediate graft function. He achieved a baseline creatinine of 1.3 mg/dL and was maintained on prednisone, tacrolimus and mycophenolate mofetil. Post transplant he developed transient BK DNAemia 3 months post transplant, with a peak copy level of 2300 copies that responded to reduction in mycophenolate mofetil. Three weeks prior to presentation he developed low grade fevers and poor appetite, followed by a dry cough 1 week later and subsequent gross hematuria. Testing for SARS-CoV-2 was negative. On physical examination, his temperature was 38.1 °C, with blood pressure of 111/71 mmHg, and pulse of 107 bpm. Examination was otherwise unremarkable. Laboratory testing was notable for an increase in serum creatinine to 2.25 mg/dL, 2+ proteinuria and hematuria on dipstick, with a urine protein-creatinine ratio of 0.7, and adenovirus PCR of 977,000 copies/mL A kidney transplant ultrasound was unremarkable. Kidney biopsy showed adenovirus nephritis(figure 1). His mycophenolate mofetil was stopped and he received cidofovir 4 mg/kg on days 0, 2, and 9 with probenecid premedication. His adenovirus PCR declined to 0 copies/mL with treatment and his creatinine improved to baseline. 1Watcharananan S.P. Avery E. Ingsathit et al.Adenovirus disease after kidney transplantation: course of infection and outcome in relation to blood viral load and immune recovery.Am J Trans. 2011; 11: 1308-1314Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 2Lusco M.A. Fogo A.B. Najafian B. Alpers C.E. AJKD Atlas of Renal Pathology: Adenovirus Infection.Am J Kid Dis. 2018; 71: e1-e2Abstract Full Text Full Text PDF Scopus (1) Google Scholar.