He had been well without infective symptoms in the weeks preceding transplantation. The donor had undergone a cardiovascular-related
death with no symptoms of recent infection, and the recipient of the other donor kidney remained well. Limited investigations were carried out (Table 1), and an infectious diseases opinion was sought. It was considered that the temporal course of the arthropathy, reassuring history relating to the potential for donor-transmitted infection, and normal culture and serology results, made an infective cause of the polyarthritis whilst still possible, highly unlikely. Acute inflammatory arthritis from a flare of RA or other acute autoimmune process was considered. Lupus serology including ANA, ENA and complements were within normal parameters. In the setting of high-dose immunosuppression, a rheumatological opinion considered RA flare unlikely, selleck inhibitor though unable to be excluded. Continuation and subsequent wean of high-dose steroids was recommended. Administration of disease-modifying agents including biologics was not advised due to diagnostic uncertainty and excessive risk with immunosuppression escalation, particularly when considering the potential for undiagnosed donor-transmitted infection. Given the ongoing severity BI 6727 nmr of the patient’s symptoms, only partial response to high-dose steroids, and suspicion of a medication-related
adverse event, a change in management was instituted on day 16. Following
a single pulse of intravenous methylprednisolone (250 mg), the tacrolimus was changed to cyclosporine A and the mycophenolate mofetil to azathioprine 1.5 mg/kg daily; the severity of symptoms at the time dictating a change in both medications simultaneously. Rapid improvement in the patient’s inflammatory markers and arthritis occurred by 48 h, with normalization of CRP within a week (Fig. 1). The patient remained well and arthritis-free with a normal CRP Galactosylceramidase for the next three months. Prednisolone was weaned slowly, with the patient still on 30 mg by 4 weeks post-transplantation and 20 mg at 8 weeks. Ten weeks after transplantation the creatinine rose to 158 μmol/L and a renal transplant biopsy showed borderline acute cellular rejection (Banff ’97 score: i1, ti2, t1, ci1, ct1, cg1). He was treated with intravenous methylprednisolone 250 mg daily for three days followed by 20 mg of prednisolone daily, and changed from azathioprine to mycophenolate mofetil 1 g BD. He did not experience any recurrence of joint symptoms. The patient is now 18 months post transplantation. He is maintained on prednisolone 10 mg daily, mycophenolate mofetil 500 mg BD and cyclosporine A. He has had no further rejection or recurrence of acute inflammatory arthritis. Attempted further reduction of prednisolone has aggravated the patient’s chronic joint symptoms.