CLINIC:
VISIT DATE:
ATTENDING PHYSICIAN:
Pediatric Renal Transplant Clinic
08/03/2006
Minnie M Sarwal, M.D., Ph.D.
IDENTIFICATION: The patient is a 14-year-old male with endstage renal
disease secondary to medullary cystic renal disease status post livingdonor renal transplant on 04/12/2006. He is attending today for a
posttransplant scheduled clinic visit. Three-month protocol biopsy for
the patient revealed evidence of Banff 1B rejection with B-cell
infiltrates, and he was admitted and treated in-house with Solu-Medrol
pulses and commenced on a course of rituximab therapy. He has received
2 doses and will receive his 3rd dose today. He is also on the steroid
avoidance therapy and continues to receive an extended dose of Zenapax
until the 6th posttransplant month. His creatinine remains stable at
0.9. Following his rejection episode, his CellCept axis has increased
from 500 mg to 50-500 mg b.i.d. Donor-specific antibodies have been
checked. The results of these are as of yet unavailable.
REVIEW OF SYSTEMS: No specific complaints of fevers, nausea, vomiting,
headache, diarrhea, or dysuria. No gastrointestinal intolerance with
increased CellCept dosing. Remainder of review of systems is
unremarkable. No allergies of note.
FAMILY AND SOCIAL HISTORY:
Unchanged.
MEDICATIONS:
1. Prograf 6 mg in the morning, 5.5 mg in the evening.
2. CellCept 500 mg b.i.d.
3. Aspirin 81 mg daily.
4. Valcyte 450 mg daily.
5. Septra 1 single strength daily.
6. Sodium bicarbonate 650 mg t.i.d.
LABORATORY DATA: Most recent labs from 07/27/2006: creatinine 0.9, BUN
12. Labs from today are pending.
PHYSICAL EXAMINATION:
VITAL SIGNS: Weight is 33.6 kg. Height is 140.2 cm. Blood pressure
is 111/68.
HEENT exam unremarkable.
NECK: Supple, with no adenopathy or masses.
CHEST: Clear to auscultation. Heart sounds normal, with no murmurs.
ABDOMEN: Soft. Allograft firm, nontender, no overlying bruit.
Midline scar.
EXTREMITIES: Clear of edema.
MUSCULOSKELETAL: Unremarkable.
NEUROLOGIC: Grossly unremarkable.
GU: Deferred.
ASSESSMENT: The patient is status post surveillance biopsy-proven
Banff 1B rejection with B-cell infiltrates. Stable creatinine running
around 0.7 to 0.8 mg/dL, with the last creatinine more elevated at 0.9
mg/dL. Repeat labs from today are pending. He has mild metabolic
acidosis.
We made the following recommendations today:
1. Check his bicarbonate from today. If normalizing, consider
discontinuing sodium bicarbonate.
2. Nurse visit next week and M.D. visit the week after.
3. Complete course of Rituxan to a total of 4 weekly doses.
4. Consider surveillance biopsy in early October to follow resolution
of biopsy-proven rejection.
5. Check NPA level. If low, consider further increasing his CellCept
axis, as the patient's baseline immunosuppression has always been
stable and his rejection implies failure of his maintenance
immunosuppression.
6. Continue to check donor-specific antibodies monthly, as well as CMV
and EBV PCRs monthly.