title: Rituximab therapy and reduction of immunosuppression to rescue graft function after renal posttransplantation lymphoproliferative disorder found by macrohematuria in a pancreas and kidney transplant recipient: a case report.
abstract: BACKGROUND
  Posttransplantation lymphoproliferative disorder (PTLD) remains an uncommon complication of solid organ transplantation, with a high mortality rate reported after conventional therapies. Epstein-Barr virus (EBV) may cause PTLD, but most EBV infections after transplantation are clinically silent reactivations, so the detection of PTLD is often delayed. Recently we experienced the rare case of intrarenal graft PTLD found by macrohematuria in a simultaneous pancreas and kidney transplant recipient. The grafts were saved by treatments with rituximab, cyclophosphamide, hydroxydaunorubicin, and prednisone-based chemotherapy (R-CHOP) after reduction of immunosuppression (IR).
  
  
  METHODS
  This 37-year-old man with insulin-dependent diabetes underwent simultaneous pancreas and kidney transplantation (SPK) with enteric drainage. Six months after transplantation, he displayed macrohematuria, which we investigated by blood tests, computer tomography (CT) scan, positron emission tomography (PET)-CT, and magnetic resonance imaging, recognizing a tumor in the transplanted renal graft. An open biopsy showed a CD20-positive PTLD. We started treatments with IR, rituximab (375 mg/m(2), weekly for 2 cycles) and R-CHOP therapy: rituximab (375 mg/m(2)) plus CHOP every 3 weeks for 6 cycles.
  
  
  RESULTS
  IR and R-CHOP therapy achieved a complete remission (CR). CR has continued for 14 months at the time of writing. The maximum level of EBV DNA was 259 copies/μg DNA, but 2 months after these therapies, the level had decreased to normal. The patient had no impairment of pancreas and kidney graft functions.
  
  
  CONCLUSIONS
  The outcome of intragraft PTLD in the kidney of an SPK recipient suggested that the negative impact of IR on graft function may be compensated by the immunosuppressive effects of rituximab, allowing reduced immunosuppression during chemotherapy.
authors.affiliation: Division of Transplantation, Reconstruction, and Endoscopic Surgery, Tohoku University, Sendai, Japan. msmsmiyagi@yahoo.co.jp
authors.forename: S
authors.initials: S
authors.lastname: Miyagi
authors.forename: S
authors.initials: S
authors.lastname: Sekiguchi
authors.forename: N
authors.initials: N
authors.lastname: Kawagishi
authors.forename: Y
authors.initials: Y
authors.lastname: Akamatsu
authors.forename: K
authors.initials: K
authors.lastname: Satoh
authors.forename: I
authors.initials: I
authors.lastname: Takeda
authors.forename: D
authors.initials: D
authors.lastname: Fukushima
authors.forename: Y
authors.initials: Y
authors.lastname: Kobayashi
authors.forename: K
authors.initials: K
authors.lastname: Tokodai
authors.forename: K
authors.initials: K
authors.lastname: Fujimori
authors.forename: S
authors.initials: S
authors.lastname: Satomi
mesh_terms: D000328:Adult; D058846:Antibodies, Monoclonal, Murine-Derived / Q000494:pharmacology* / Q000627:therapeutic use; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D003520:Cyclophosphamide / Q000627:therapeutic use; D004317:Doxorubicin / Q000627:therapeutic use; D020031:Epstein-Barr Virus Infections / Q000150:complications; D006417:Hematuria / Q000175:diagnosis*; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D007680:Kidney Neoplasms / Q000175:diagnosis / Q000628:therapy; D016030:Kidney Transplantation / Q000009:adverse effects* / Q000379:methods*; D008232:Lymphoproliferative Disorders / Q000209:etiology*; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D016035:Pancreas Transplantation / Q000379:methods*; D049268:Positron-Emission Tomography / Q000379:methods; D011183:Postoperative Complications; D011241:Prednisone / Q000627:therapeutic use; D012074:Remission Induction; D000069283:Rituximab; D014057:Tomography, X-Ray Computed / Q000379:methods; D014750:Vincristine / Q000627:therapeutic use
chemical_list: D058846:Antibodies, Monoclonal, Murine-Derived; D007166:Immunosuppressive Agents; C571759:R-CHOP protocol; D000069283:Rituximab; D014750:Vincristine; D004317:Doxorubicin; D003520:Cyclophosphamide; D011241:Prednisone