PaJR Case Reports: 38M CKD Post Renal Transplant 8 years Recent Failure and Re Dialysis 6 months Telangana PaJR

02-07-2025

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

[02-07-2025 19.56] PPM 1: 🧾 Clinical Case Summary – Timeline Format

🩺 Renal Allograft Recipient with Graft Dysfunction and HFpEF

📍 Shared for Academic Discussion / Case Presentation

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🧑‍⚕ Patient Profile:

Age at Transplantation: 31 years

Sex: Male

Known CKD Etiology: Not documented initially

Donor: Mother (aged 50–51 years at time of transplantation)

COVID-19 Vaccination: Received Covishield (ChAdOx1) in 2020

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🧬 Childhood & Family History:

👶 Childhood History:

No known history of childhood renal disease

No history of recurrent urinary tract infections

No history of nephrotic syndrome or glomerulopathies in early life

Normal developmental milestones

Immunizations taken as per schedule (unspecified)

🧬 Family History:

Mother: Donor for renal transplantation, otherwise healthy at time of donation (~50–51 years)

No family history of:

Chronic kidney disease

Diabetes mellitus

Hypertension

Autoimmune or hereditary nephropathies

No consanguinity reported

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🗓 Detailed Clinical Timeline:

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🔹 Initial Decompensation (~8–9 Months Pre-Transplant):

• Symptoms: Sudden onset dyspnea, bilateral pedal edema, altered sensorium

• Admitted to Superaja Hospital (instead of planned Global Hospital consultation)

• Diagnosed as CKD-V with uremic symptoms

• Emergency dialysis initiated

• Hospitalized for 4 days → Continued as day-care hemodialysis

• Referred to Dr. Sandeep (Nephrologist, Global Hospital) for transplant work-up

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🔹 Global Hospital Evaluation & Diagnosis:

• Serum creatinine: ~14 mg/dL

• Ultrasound: Bilaterally shrunken kidneys

• Diagnosis: End-stage renal disease (CKD Stage V)

• Recommendation: Live-related renal transplantation

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🔹 Renal Transplantation:

• Donor: Mother (aged ~50–51 years)

• Recipient age: 31 years

• Transplant status: Successful; no perioperative complications reported

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🔹 Post-Transplant Period (~4 Years):

• Dialysis-free status maintained

• Resumed routine activities without limitation

• On maintenance immunosuppression (likely MMF + steroid ± CNI)

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🔹 Year 4 Post-Transplant – Gouty Arthritis:

• Complaints: Joint pain, swelling, elevated uric acid

• Underwent renal allograft biopsy

• Treated pharmacologically → Symptomatically improved

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🔹 One Year Later – Constitutional + GI Symptoms:

• Recurrent fever, loose stools, generalized fatigue

• PET-CT scan: Normal metabolic activity

• Gastroenterology opinion: MMF-induced GI toxicity suspected

• Referred back to nephrology for dose modification

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🔹 Immunosuppressive Adjustment:

• MMF dose reduced from 500 mg → 350 mg

• Initiated on: Ajran (specific drug pending clarification)

• Maintained on this regimen × 5–6 months → Symptom-free

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🔹 Subsequent Clinical Relapse:

• Symptoms: Recurrence of fever, diarrhea

• Repeat renal biopsy:

◦ ~10% decline in graft function

◦ Diagnosis: Chronic allograft nephropathy

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🔹 Re-initiation of Hemodialysis:

• Complaints: Tachypnea, shortness of breath, myalgia, functional decline

• Hemodialysis reinitiated → Significant symptomatic improvement

◦ Resolution of GI symptoms and fevers

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🔹 Medication Compliance Concerns:

• History of intermittent non-adherence to immunosuppressants

• Likely contributor to progressive allograft dysfunction

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🔹 Recent Status (Past 1 Month):

• Dyspnea progressed:

◦ MMRC Grade 3 → Grade 4, NYHA Class IV

• Bilateral pedal edema (Grade 2)

• Echocardiography:

◦ Global LV hypokinesia

◦ Preserved ejection fraction

• Diagnosis: Heart Failure with Preserved Ejection Fraction (HFpEF)

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🔹 COVID-19 Vaccination History:

• Received Covishield in 2020

• Family reports noticeable symptom worsening after vaccination

◦ Clinical causality: Temporal association only (no documented adverse event or biopsy correlation)

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🏥 Current Clinical Status:

• Admitted to ICU

• Persistent exertional dyspnea, generalized weakness

• Unable to perform ADLs

• On maintenance hemodialysis

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📂 Pending Attachments:

Renal Biopsy Reports

Blood Investigations

Imaging (TTE, USG, PET-CT)

Immunosuppressive chart

Dialysis log sheets

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🧠 Summary Impression:

Chronic Allograft Dysfunction with repeat renal biopsy-confirmed function loss, requiring reinitiation of dialysis, complicated by gastrointestinal intolerance to immunosuppressants, and now presenting with HFpEF and NYHA Class IV decompensation.

[02-07-2025 21.44] PPM 1: 38y/M

Diagnosis

- Acute pulmonary edema (resolved) secondary to CAD

- Heart failure with Preserved Ejection Fraction

- CKD (Stage V) on MHD

- K/c/o HTN x 10yrs

- S/P Rt Renal Transplant

- Anemia of Chronic Disease

- S/P 1 session of hemodialysis done on 01/07/25