A case report of post transplant lymphoproliferative disorder after kidney transplantation

We report a case of 46 year-old man who had Epstein-Barr virus (EBV)-associated lymphoproliferative disorder (LPD) after living related donor kidney transplantation. The patient who had been on hemodialysis due to the end stage of renal disease, secondary to chronic glomerulonephritis, received a kidney transplant from his mother (ABO blood type minor mismatch kidney transplantation from O(+) to A(+), HLA-A, B 1 haplo identical). Under tacrolimus (FK) quadruple therapy (FK, Azathioprine (AZ), Methylprednisolone (MP), and antilymphocyte globulin (ALG)) and the irradiation of 4.5 Gy to the graft, he suffered acute rejection on post operative day 10 and 22. Graft biopsy showed acute rejection (Banff classification AR-I b and AR-0-I, respectively), so we treated the rejection by 2 times MP pulse therapy (500 mg/day for 2 days) and administration of OKT 3 for 10 days. Post operative day 34, the serum creatinine level elevated from 2.3 mg/dl to 2.7 mg/dl. So we performed the third graft biopsy which showed acute rejection (Banff classification AR-I b) and lymphoproliferative disorder, most likely. Tacrolimus was changed to cyclosporine A and gancyclovir was administered. But the elevation of serum creatinine level was continued, the fourth graft biopsy on post operative day 41 showed AR II on Banff classification and lymphoproliferative disorder. Post operative day 42 we performed graftectomy. Pathological diagnosis was lymphoproliferative disorder and AR II on Banff classification. Administration of gancyclovir and acyclovir continued. Post graftectomy, he had right axillary lymphnode swelling on computed tomography post operative day 57 and 71. We resected the lymphnodes which showed reactive histiocytosis in the immunosuppressive state. He discharged post operative day 80 and has no evidence of disease at present.