Beyond Anemia of CKD: A Tale of Discovering Post-transplant Lymphoproliferative Disorder by Colonoscopy

Introduction: In young patients seldom are drops in hemoglobin investigated with colonoscopy. In chronic kidney disease (CKD) patients, anemia is attributed to CKD and further testing is often met with resistance especially in younger population. Our rare case describes how a nephrologists referral for anemia diagnoses post-transplant lymphoproliferative disorder (PTLD) in the form of colon lymphoma. This highlights the important role nephrologist play in caring for transplant patients. Case Description: A 31-year-old male with congenital nephrotic syndrome (Finnish type) post living related kidney transplant 3/30/2006 is referred by nephrologist for inpatient workup of diarrhea and anemia. Exam revealed pale and toxic appearing young male with admission labs of Na 125, K 5.9, Cl 96, HCO3 16, BUN 73, Cr 3.64 and WBC 12.99, Hb 6.6, Hct 20.8 and PLT 403. Stool pathogen was positive for Yersinia Enterocolitica and E.coli (EPEC). CT imaging revealed pleural effusion and no lymphadenopathy. Although patient responded to transfusion, nephrology team had extensive discussion to pursue endoscopy which gastroenterology finally agreed. EGD/Colonoscopy revealed multiple polypoid non-obstructing medium sized masses in descending colon, transverse colon and ascending colon and multiple superficially ulcerated nodules in recto-sigmoid and sigmoid colon. Pathology diagnosed diffuse large B-cell lymphoma (DLBCL) negative for CD-20. Immunosuppression was reduced and patient was discharged however outpatient PET found mesenteric lymphadenopathy. Even though oncology initiated chemotherapy, the patient suffered septic shock due to enterotoxigenic E.coli after first treatment and expired. Discussion: Immunosuppressed kidney transplant recipients are at higher risk of developing malignancy including gastroenterology cancer. However current guidelines for testing and screening do not differ between the transplant and general population. Therefore continued sense of awareness and advocacy for screening is important. Evidence based guidelines in this population is needed to improve life expectancy in kidney transplant patients.