BK virus nephropathy in a renal transplant patient Potential role of electron microscopy in diagnosis r n e f r o l o g i a 2 0 1 6;3 6(5) 556–581 565 7 Keller FS, Coyle M, Rosch J, Dotter CT Percutan[.]
Trang 1nefrologia.2016;3 6(5):556–581 565
SandraSilvaa , ∗,RicardoPereirab,IvoCunhab,
CarlosFerreirac,AnaBrancoa,EduardoEirasb,
MrinaliniHonavard,JoanaSimõesb,TeresaSantosa,
TeresaChuvaa, JoséCostaa
aNephrology, Hospital Pedro Hispano, Porto, Portugal
bInternal Medicine, Hospital Pedro Hispano, Porto, Portugal
cUrology, Hospital Pedro Hispano, Porto, Portugal
dPathology, Hospital Pedro Hispano, Porto, Portugal
∗Corresponding author.
E-mailaddress:oliveirasilva.sandra@gmail.com(S.Silva) 2013-2514/©2016SociedadEspa ˜noladeNefrolog´ıa.Published
byElsevierEspa ˜na,S.L.U.Thisisanopenaccessarticleunder theCCBY-NC-NDlicense(http://creativecommons org/
http://dx.doi.org/10.1016/j.nefroe.2016.11.004
Dear Editor,
oneofthemaincausesofallograftfailureinrenaltransplant
patients.Acuterejectionanddifferentviralinfectionsshould
beconsideredindifferentialdiagnosisofrenalallograft
dys-function.Electronmicroscopy(EM)couldhelptodistinguish
BKVfrom otherviralfactorsinallografttissue.2 Herein,we
describedinclusionsduetoBKVseenbyEMinarenal
trans-plantbiopsyandwediscussedpotentialroleofEMindiagnosis
ofBKVN
A 49 years old woman had renal transplantation from
non-relative donor2 years ago Although shewas
asymp-tomatic,herserumcreatininelevelwasincreasedgradually
during last 3–4 months (from 1.2mg/dl to 1.7mg/dl) Her
primary renal disease was unknown She had been under
the treatment of tacrolimus 2+1mg, prednisolone 5mg,
mycophenolatesodium3×360mg.Physicalexaminationwas
normal.Serumcreatinine was1.82mg/dl,urinemicroscopy
wasnormal.154mg/dayproteinuriawasobtained.ANAwas
positive,thoughENAwasnegative.AntiCMVIgMwas
nega-tive,whereasserumBK/JCPCRwaspositive.Serumtacrolimus
levelwas9.5ng/ml.Transplantrenaldopplerultrasonography
DOIoforiginalarticle:
revealed normal findings Renal biopsy was performed Intranuclearinclusions,cytoplasmicandnuclearenlargement
in tubular epithelial cells and tubular necrosis were seen
on light microscopy These biopsy findings might suggest viral infection ofthe renal allograft Immunohistochemical analysisoftherenalbiopsyforCMVwasnegative,butstudy withSV40antigencouldnotbeperformedasitwasnot avail-ableinourcenter.Intranuclearsphericalviralparticleswere seeninsometubularepithelialcellsonEM(Fig.1 Viral par-ticles were inparacrystallinestructureand about 30nmin diameter.Theyweredifferentiatedfrominclusionsof adeno-viruswith80–100nmindiameter(Fig.2 Finally,BKVNwas diagnosed
BKVN isoneofthewell-known reasons ofmorbidityin renaltransplantpatients.Itoccurswithaprevalenceof1–10%
inrenaltransplantpatientsandgraftlossisupto80%.3,4BKVN occursmostlyduringthefirstyearaftertransplantationandit
ischaracterizedonlybydeteriorationofrenalfunctions, usu-allywithoutanysymptoms.1Earlydiagnosisisimportantto preventallograftdysfunction inkidney transplant patients Ourpatientwasalsodeclarednosymptoms,butonlya grad-ualincreaseinserumcreatininewasobservedinthesecond yearoffollowup
ThepathogenesisofBKVNischaracterizedbyhighgrade BKVreplicationinrenal-tubularepithelialcellsofrenal allo-graft Necrosisoftubular cells letBKVleak into the tissue
Trang 2566 nefrologia.2016;3 6(5):556–581
Plasmaandurinepolymerasechainreaction(PCR),urine
cytology, and urine electron microscopy (EM) can be
per-formed in diagnosis of BKVN whereas renal biopsy is the
goldstandardmethod.3,5Multiplebiopsyshouldbeperformed
because of multi-focal involvement to prevent sampling
errors and biopsy specimen should contain medullary
parenchyma as the virus is more likely to present in the
medulla.5 Intranuclear inclusions,lysisornecrosisof
tubu-lar cells showing tubulointerstitial inflammation could be
observed on light microscopy However, changes observed
duringlight microscopy are notpathognomonic forBKVN
Immunohistochemistry (SV40 staining) and EM should be
performed.6
Herpessimplexvirus,adenovirus,CMV,Epstein–Barrvirus
(EBV) should also be considered in differential diagnosis
30–50nmindiameterandoccasionallyformcrystalloid struc-tures, whereas inclusions due to family of herpesviridae (including Herpes simplex, EBV and CMV) and aden-oviruses are bigger in size (120–150nm and 70–90nm respectively).2,6,9,10
In our patient, size of the viral particles was 30nm in average.Althoughlightmicroscopicdetectionofintranuclear inclusionssuggestedviralinfectionofrenalallograft,itwas theEMthatdefineddimensionsofinclusionsandhelpedthe diagnosis.Inconclusion,EMevaluationofallograftbiopsymay
be importantinthe differential diagnosis ofdifferent viral infectionsofallograft
Conflicts of interest
r e f e r e n c e s
2000;15:324–32
179–88
2015;30(2):209–17
1999;10:1080–9
2007;31(3):199–207
1277–86
Trang 3nefrologia.2016;3 6(5):556–581 567
SimgeBardaka , ∗,KenanTurgutalpa,EbruBallıb,
BanuCos¸kunYılmazb, ˙IclalGürsesc,KaanEsend,
SerapDemira, AhmetKıykıma
aDivision of Nephrology, Department of Internal Medicine,
School of Medicine, Mersin University, 33079 Mersin,
Turkey
bDepartment of Histology and Embryology, School of Medicine,
Mersin University, Turkey
cDepartment of Pathology, School of Medicine, Mersin University,
Turkey
dDepartment of Radiology, School of Medicine, Mersin University, Turkey
∗Corresponding author.
E-mailaddress:bardaksimge@gmail.com(S.Bardak) 2013-2514/©2016SociedadEspa ˜noladeNefrolog´ıa.Published
by Elsevier Espa ˜na, S.L.U This is an open access article undertheCCBY-NC-NDlicense(http://creativecommons.org/
http://dx.doi.org/10.1016/j.nefroe.2016.08.005
Dear Editor,
compli-cationsintheabdominalwall,particularlyhernias.Itmayalso
contributetothefailureofultrafiltration,anditmaybecause
ofabandonmentofthetechnique
Theaimofthestudywastoassessthefrequencyofhernias,
identifytheriskfactorsforthedevelopmentofherniaandto
determinewhetherornottheyleadtofailureofthedialysis
technique
Westudiedprevalentpatientsonperitonealdialysisatday
01August2015intheComplejoAsistencialUniversitariode
Leon,inLeon,Spain.Weanalysedthevariables:age;gender;
type;timeondialysis;presenceofpolycystickidneydisease;
history of abdominalsurgery; diagnosis and repair of
her-niabeforestartingdialysis;anthropometricparameters(body
massindex(BMI),fattissueindex(FTI)andleantissueindex
(LTI)measured by bioimpedance);daytime/scvolume;
noc-turnal/scvolume;residualvolume;andIPPandultrafiltration
measuredbyaperitonealequilibrationtest.Wecomparedthe
groupofpatientwithherniaswiththegroupwithouthernias
Continuousvariableswereexpressedasmeanandstandard
deviation;inthecaseofdiscretevariables,absolute
frequen-ciesandpercentagesareprovided.Theassociationbetween
qualitativevariableswasevaluatedwiththechi-squaretest
andquantitativevariablesusingStudent’s2-tailedt-test.For
thecomparisons,thetestswereconsideredtobesignificant
DOIoforiginalarticle:
夽Pleasecitethisarticleas:SastreA,González-ArregocesJ,RomainoikI,Mari ˜noS,LucasC,MonfáE,etal.Factoresderiesgoasociados
aherniasendiálisisperitoneal.Nefrologia.2016;36:567–568
when p<0.05.SPSS® statistical software forWindows was used
We analysed 44 patients, 27 males (61.4%), 17 females (38.6%), 28 on continuous ambulatory peritoneal dialysis (CAPD) (63.6%), the average time on dialysis 27.63±19.1 months,3PKD(6.8%),22hadahistoryofabdominalsurgery (50%)and8(18.8%)hadaherniarepairpriortostartingdialysis Therewere8hernias(18.8%),3umbilicaland5inguinal,
7 in males (87.5%), 50% on CAPD In 6 patients, the pre-scriptionwaschangedtoautomatedperitonealdialysis(APD) withadryday,onepatientremainedon CAPDwith reduc-tion ofvolume/sc;withtheseprescription changes,6(75%) patientsremainedasymptomaticandwithoutcomplications suchasincarcerationorstrangulation.Onehernia(12.5%)was repairedsurgicallywithmeshimplant,andthepatientwas switchedtemporarilytohaemodialysisduetothepresenceof persistentpain
Therewerenodifferencesbetweenpatientswithhernias
or without hernias in the variables age, dialysis modality, BMI,FTI,LTI,timeondialysis,volume/sc,ultrafiltrationand IPP In contrast, there was greater residual volume in the patientswithhernias:467±61.8comparedto360.9±116ml
(p0.017).ThereweremoresubjectswithPKDandmorewith herniasandpreviousabdominalsurgeryinthegroupwith her-nias(p<0.05)(Table1 100%ofthegroupwithhernias had IPP>13cm/H2O
Weanalysedthe34patientswhohadIPP>13cm/H2Oand compared them to those with lower IPP Time on dialysis