Infections, Immunosuppressants, and Focal Segmental Glomerulosclerosis Transplants: A Never-ending Challenge

Dear Editor, Renal transplantation is a crucial treatment modality for end-stage renal disease, offering an improved quality of life and long-term survival. However, immunosuppressive therapy in transplant recipients increases the risk of infectious complications. Here, we present the clinical journey of a 25-year-old male renal transplant recipient with focal segmental glomerulosclerosis (FSGS) who faced a series of complex infections. The patient experienced a series of challenging complications, including hepatitis C virus (HCV) infection, pulmonary tuberculosis, new-onset diabetes after transplantation (NODAT), and multiple opportunistic infections posttransplantation. The 25-year-old male was diagnosed with FSGS in 2018 and was on immunosuppressants for the same, but within 6 months of the illness, he progressed to chronic kidney disease (CKD) stage 5D in 2019. In 2022, he was diagnosed with an HCV infection followed by pleural effusion due to tuberculosis and was treated for both. After 3 months of antituberculosis treatment, he underwent a live-related renal transplant on August 26, 2022, and had good graft function. However, he developed NODAT, which was managed with oral hypoglycemic agents. The patient also had persistent 3+ (2.8 g/24 h) proteinuria posttransplant, leading to a renal biopsy, which was inconclusive. Subsequently, he presented with severe headache with magnetic resonance imaging showing hypointense lesions [Figure 1], and cerebrospinal fluid revealed the diagnosis of cryptococcal meningitis. He was treated with antifungals and improved.Figure 1: Magnetic resonance imaging brain (coronal and sagittal view) showing multiple ring enhancing lesions with peri lesional oedema and High resolution computed tomography (HRCT) thorax showing large consolidation in left and right upper lobe with multiple small heterogenous opacities in other areasIn March 2023, the patient had a lower respiratory tract infection, and High resolution computed tomography (HRCT) showed multiple homogeneous opacities in bilateral lungs [Figure 1]. Sputum study suggestive of co-infection of Nocardia and aspergillosis and was treated with liposomal amphotericin and imipenem with trimethoprim–sulfamethoxazole.[1] His tacrolimus level was found to be 34 ng/ml on 0.5 mg twice daily, and the dose was reduced to 0.5 mg every alternate day to maintain levels around 3–4 ng/ml. Due to persistent proteinuria, a repeat renal biopsy was performed, showing the recurrence of FSGS [Figure 2]. Plasmapheresis was not done as the patient had multiple infections; hence, proteinuria was managed with Angio te sin converting enzyme (ACE) inhibitors. The patient was doing well with 1000 mg of proteinuria in 24 h and a serum creatinine of 1.2 mg/dl, but he threw one seizure Generalised tonic clonic seizure (GTCS) at home and succumbed due to aspiration.Figure 2: Allograft biopsy showing focal segmental glomerulosclerosis pattern (recurrence of the native disease) and Electron microscopy (EM) study showing diffuse effacement of the foot processes of the podocytesPosttransplant infections are commonly seen due to the immunosuppressive therapy that patients undergo. The possible explanations/contributory factors for this could be native kidney disease of FSGS with heavy proteinuria, which was treated with immunosuppression before transplant, making the patient more susceptible to infections. The persistent proteinuria in the posttransplant period, infrequent tacrolimus level monitoring due to financial constraints, and poor nutritional status of the patient before and after renal transplantation may be the contributory factors.[2] The persistent HCV infection in the pretransplant period is known for its immunomodulatory activity. NODAT due to immunosuppressant drugs predisposed with steroid, tacrolimus, and HCV infection, added fuel to the risk of infections.[1] In an article published in 2019 by Gupta et al.,[3] a total of 1270 patients were studied, of which 231 infectious episodes were detected in 196 (15.4%) patients with bacterial infection in 5.9%, followed by tuberculosis in 4.9%, viral in 3.8%, and fungal in 2.1% were the infections encountered. This case, however, highlights the complexity and rare occurrence of simultaneous viral, fungal, bacterial, and tubercular infections in a short period of pre- and posttransplantation within one patient. In conclusion, this case highlights the rare occurrence of simultaneous viral, fungal, bacterial, and tubercular infections in a renal transplant recipient with a recurrence of FSGS. Despite the challenges faced, the patient initially responded well to treatment and achieved graft function with manageable proteinuria but succumbed due to aspiration. This case underscores the importance of vigilant monitoring, early detection, and prompt management of infectious complications in renal transplant recipients. Declaration of patient consent The patient consent has been taken for participation in the study and for the publication of clinical details and images. Patients understand that the names and initials would not be published, and all standard protocols will be followed to conceal their identity. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.