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Case Study
One Pediatric Patient’s Experience
Shelley Chapman RN, BSN, CCTC
Children’s Hospital of Wisconsin
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Patient History

15 year old Caucasian male

Past medical history
 Liver transplant
 3 year old
 Fulminant liver failure of
unknown etiology
 Bone marrow transplant
 12 years old
 Aplastic anemia
 Kidney transplant
 13 years old
 Immunosuppression
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Patient Presentation

Presented to the Renal Clinic
 5 day history of dysuria
 2 day history of gross hematuria
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Labs
 Creatinine elevated at 1.49mg/dl
 Increased from his baseline of
0.8mg/dl

Hospital admission
 Further evaluation and presumed
rejection
 Renal ultrasound was done to
evaluate for stones
 IV fluids on the day of admission
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Patient Presentation:
The Next 48 Hours
Creatinine
• Peaked at 5.13mg/dl
Kidney
Biopsy
• Biopsy scheduled
• Dose of Methylprednisolone given
• No rejection or signs of acute interstitial nephritis
Viral
Studies
• Biopsy
• Blood
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Patient Presentation Cont.
Viral Studies
Adenovirus
POSITIVE
50,000 copies
PCR
ID and BMT
Consult
CMV
EBV
BK
Negative
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Treatment


Recommended treatment for
Adenovirus s/p BMT

Cidofovir and Probenecid

Side effect is nephrotoxicity
Alternate prodrug formulation
of Cidofovir (CMX001)
recommended
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Drug currently in clinical
trials
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Treatment Continued

The Adenovirus PCR peaked
at 137,000 copies

Slowly improved

Experienced intermittent
fevers without bacteremia
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Immunosuppression changes


DC Mycophenolate Mofetil

Continued on Tacrolimus
and Prednisone
Patient discharged to home
after 10 days
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Outpatient Treatment & Follow-up
CMX001
Outpatient
Treatment
• Administered medication 2 times per week
in BMT clinic
• Treatment for 13 weeks
Treatment
Side Effects
• Significant diarrhea
• Required home IV fluids
• Liver function studies and other labs stable
Treatment
Outcome
• Urine adenovirus positive
• Blood adenovirus negative after 5 weeks
• Creatinine returned to baseline 0.9mg/dl
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1 Year Follow-up
Creatinine
0.9mg/dl
Adenovirus
negative
No hematuria
or dysuria
+ Lessons
Learned
Do not assume patient is having rejection with
sudden and substantial decline in renal function
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Discussion and Questions