A 60-year-old man was diagnosed in another hospital in 2000 with extracapilary glomerulonephritis type III associated with C-ANCA.
She was treated with 5 intravenous boluses of 6-methylprednisolone followed by oral corticosteroids in descending order associated with oral cyclophosphamide (we could not obtain the exact dosage).
Cyclophosphamide was discontinued due to myelotoxicity.
In 2002, she was included in a regular haemodialysis programme.
In September 2006, in another center, a cadaveric renal graft was implanted.
The patient received tacrolinus as monotherapy, although we cannot ensure that he had received any other combination of tacrolinus previously.
Their serum creatinine ranged from 1.5 to 1.7 mg/dl.
In December 2013, due to the implantation of a percutaneous aortic valve in our hospital, a pre- and post-intervention assessment was performed in our service.
At that time, her clinical condition was good, with serum creatinine of 1.5 mg/dl and proteinuria 0.3 g/day, with normal urinary sediment.
In October 2014, when respiratory symptoms with fever and deterioration of renal function appeared, the patient decided to return to our hospital for clinical control.
The fever and respiratory symptoms, without microbiological or radiological evidence, improved with empirical treatment with levofloxacin.
However, renal function worsened in a few days until reaching serum creatinine of 4 mg/dl, with proteinuria of 6.8 g/day and hematuria.
The determination of C-ANCA was 74.2 IU/ml (normal values: 0-5 IU/ml) and P-ANCA 8.4 IU/ml (normal values: 0-6 IU/ml).
The rest of the autoimmunity parameters (ANA, anti-GBM antibodies, complement, cryoglobulins, etc.) were negative.
Serology HIV, HCV, HBV and CMV and BK viremia were also negative.
A renal graft biopsy was performed in which the most relevant findings were: of the 19 glomeruli that were evaluable, 3 had global glomerular manifestations, 12 glomeruli had cellular semilunarians.
Some of them had disruption of the Bowman's capsule that causes pseudogranulomatous inflammatory reaction of mononucleated cells.
Two glomeruli had lesions compatible with fibrinoid necrosis.
We found tubular necrosis in 15% tubular generation, tubular necrosis in 20% and some helminophilic cylinders, in addition to interstitial infiltrate in 25% with some eosinophil and foci of recent interstitial hemorrhage and mucoid hyperplasia of the arteriolar wall.
Immunofluorescence was negative.
Immunohistochemical study for C4d was negative.
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established/day evidence of recurrence of the underlying disease, the patient received 3 intravenous boluses of 500 mg 6-methylprednisolone (the patient was diabetic) on consecutive days, followed by oral prednisone at a dose of 0.5 mg/kg.
Also, 8 sessions of plasmapheresis were applied and treatment with mycophenolate mofetil (1 g/12 h orally) associated with tacrolimus was initiated.
Twelve days after admission, the patient was discharged with a serum creatinine of 2.9 mg/dl. In an outpatient follow-up one month later, creatinine was 2.3 mg/dl and proteinuria was 3.6 g/day.
