Renal dysfunction and hyperglycemia in a renal transplant recipient

Presentation of caseA 34-year-old Asian man was admitted to the hospital because of a rising serum creatinine level and new-onset hyperglycemia.The patient had a history of end-stage renal disease of unknown etiology, and had been receiving continuous ambulatory peritoneal dialysis for 16 months when he received a two-haplotype HLAmatched kidney from his brother at the Cornell campus of the New York Presbyterian Hospital three months prior to admission.His immunosuppressive regimen included corticosteroids, cyclosporine, and mycophenolate mofetil.Because both donor and recipient were cytomegalovirus seropositive, the patient was given prophylactic oral ganciclovir post-transplantation. Postoperatively, he was febrile to a maximum of 39æC on days 4-7, and complained of occasional bladder spasms.He received a course of oral ciprofloxacin for an E. coli urinary tract infection and defervesced.On postoperative days 7-9 he was given pulse-dose corticosteroids because of a slower-than-expected recovery of renal function.He was discharged on the tenth post-transplant day with a serum creatinine of 2.2 mg/dl.In the three months following transplantation, the patient intermittently complained of fatigue, myalgias, arthralgias, and headaches, but denied any fever.He experienced occasional episodes of gross hematuria and dysuria that resolved spontaneously.He also developed lower extremity edema and was given furosemide.Serum cyclosporine levels were maintained in the range 200-300 ng/ml but two and one half months post-transplantation, his serum creatinine, which had fallen as low as 1.6 mg/dl, slowly rose to 2.5 mg/dl.The prednisone dose was increased to 60 mg/day without any effect on his serum creatinine.Not known to be diabetic prior to transplant, the patient developed new-onset hyperglycemia on the higher prednisone dose.