Letter to the Editor
Plasmacytoma-like post-transplantation lymphoproliferative disorder in renal allograft
Enfermedad linfoproliferativa postrasplante tipo plasmocitoma sobre injerto renal
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The plasmacytoma-like variant is rare (<5%), with less than 60 cases described in the literature,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> and has received less attention than the classical forms of PTLD. We report the case of a PTLD with plasma-cell differentiation on renal allograft with retroperitoneal lymphadenopathy, which was successfully treated with rituximab.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 44-year-old man with a personal history of hypercholesterolemia, cholecystectomy, and kidney transplantation due to familial nephropathy of uncertain aetiology, and retransplantation due to end-stage graft dysfunction. During the 15 years after retransplantation, the patient remained asymptomatic, manifesting chronic graft nephropathy with stable renal function (SCr: 1.8–2.2<span class="elsevierStyleHsp" style=""></span>mg/dl), under immunosuppressant treatment with mycophenolate mofetil (750<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h), cyclosporin A (50<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h) and prednisone (5<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h).</p><p id="par0015" class="elsevierStylePara elsevierViewall">An isolated monoclonal peak was detected in a follow-up lab test. After completing the study, he was diagnosed with monoclonal gammopathy of uncertain significance (MGUS). Ultrasound showed grade 3 hydronephrosis and urothelial thickening, so an abdominal CT scan was performed in which para-aortic retroperitoneal lymph nodes and soft tissue graft infiltration were detected. These findings pointed to lymphoma as the first diagnostic possibility.</p><p id="par0020" class="elsevierStylePara elsevierViewall">PET/CT was requested, and it was decided to perform a biopsy of the lymphadenopathies, whose pathological report was a diagnosis of monomorphic B-cell PTLD with plasma-cell differentiation. Since the patient was asymptomatic, it was decided to reduce mycophenolate mofetil and administer 4 weekly cycles of rituximab. One month after the last cycle, a new PET/CT showed the disappearance of the previous lymph node uptake, without other lesions suggestive of tumour activity. In the 2-year follow-up, 2 new PET/CT scans were performed without pathological findings. Currently, the patient is asymptomatic with stable renal function in SCr values: 1.8<span class="elsevierStyleHsp" style=""></span>mg/dl.</p><p id="par0025" class="elsevierStylePara elsevierViewall">This is the fifth published case of plasmacytoma-like PTLD on renal graft,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> which also developed a retroperitoneal lymph node conglomerate that allowed the histological diagnosis to be made. The increase in the incidence of PTLD in the last decade has been attributed to several factors: greater number of transplants, older donors, new immunosuppressant agents or better diagnostic techniques.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> The kidney is the transplanted organ with the lowest incidence of PTLD (0.8–2.5%),<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> although this figure may underestimate the real incidence in up to half of the cases.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The main differential diagnosis of PTLD in renal graft is based on rejection and infection-sepsis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> In this case, the patient remained asymptomatic and his renal function was stable, with MGUS being the only notable laboratory abnormality. Therefore, these differential diagnosis were ruled out without posing any diagnostic difficulties.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The initial treatment for PTLD is based on gradually decreasing immunosuppression according to response: first discontinuation of purine synthesis inhibitors, then change from anticalcineurin agents to m-TOR inhibitors. Response rates are usually fast (2–4 weeks), reaching remissions of up to 80%. The graft function needs to be closely monitored for acute rejections at this time. There are also alternatives with little evidence, such as removal, radiotherapy (immune) chemotherapy, or hematopoietic cell transplantation. The second line of treatment in monomorphic PTLD unresponsive to the discontinuation of immunosuppression is rituximab, an anti-CD20 monoclonal antibody. It is administered for 4 weeks, at a rate of 375<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span>/week, although there is no unanimity regarding the dose and duration. Response rates reach 80%, with complete remissions up to 55%. The authors wish to highlight the importance of rituximab in this group of patients, as shown in the case reported, although its efficacy must be confirmed by larger series.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Láinez Ramos-Bossini AJ, Moyano Portillo Á, Ruiz Carazo E. Enfermedad linfoproliferativa postrasplante tipo plasmocitoma sobre injerto renal. 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