Korean J Transplant.  2022 Dec;36(4):289-293. 10.4285/kjt.22.0048.

Successful treatment of renal malakoplakia via the reduction of immunosuppression and antimicrobial therapy after kidney transplantation: a case report

• Yim SH
• Min EK
• Kim HJ
• Lim BJ
• Huh KH

• KMID: 2537541
• DOI: http://doi.org/10.4285/kjt.22.0048

Abstract

Malakoplakia is a rare, granulomatous disease that usually affects immunocompromised individuals and is generally associated with poor graft and patient survival. We present a case of renal malakoplakia after kidney transplantation (KT). A 33-year-old female patient with chronic kidney disease underwent living-donor KT at Severance Hospital. The patient was administered 375 mg/m² rituximab due to high panel reactive antibodies. Immunosuppression was initiated with 1.5 mg/kg anti-thymocyte globulin and intravenous methylprednisolone and maintained with tacrolimus, oral methylprednisolone, and mycophenolate mofetil (MMF). Six months after KT, the patient was hospitalized for a urinary tract infection with an elevated serum creatinine level of 3.14 mg/dL. Renal biopsy revealed malakoplakia involving the renal parenchyma. Upon this diagnosis, the dose of tacrolimus was reduced and MMF was stopped. Fluoroquinolone was used for 16 days, and the trimethoprim/sulfamethoxazole dose was doubled for 6 days. The patient was hospitalized for 3 weeks and closely observed during outpatient visits. Follow-up ultrasonography revealed mass-like lesions of renal malakoplakia, which disappeared 5 months after diagnosis. The serum creatinine level decreased to 1.29 mg/dL 28 months after diagnosis. Our results suggest that renal malakoplakia can be successfully treated by the reduction of immunosuppression and sustained antimicrobial therapy.

Keyword

Malakoplakia; Kidney transplantation; Immunosuppression; Graft rejections; Case report

Figure

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  Fig. 1 Microscopic image of malakoplakia. (A) Periodic acid-methenamine silver stain (×400); interstitium showing heavy infiltration of macrophages. (B) Periodic acid-Schiff (PAS) stain (×400); interstitium showing heavy infiltration of macrophages with PAS-positive granules. (C) CD68 stain (×400).

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  Fig. 2 Serial trough levels of tacrolimus.

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  Fig. 3 Change in antibiotics and doses used. TMP/SMX, trimethoprim/sulfamethoxazole.

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  Fig. 4 Ultrasonographic images of malakoplakia in the kidney. (A) Malakoplakia lesion in mid-portion of transplanted kidney, diameter is 4.39 cm. (B) Another malakoplakia lesion in upper pole of transplanted kidney, diameter is 5.80 cm.

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  Fig. 5 Serum creatinine levels.

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