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What is wrong with my husband's kidneys?

Q: My husband had a kidney transplant 2.5 months ago, right after the transplant he had a mild to moderate rejection episode, and had to be re-hospitalised, and given a strong dose of steroids for 4 days. Since then he has been doing really well with his creatinine levels. Currently he is maintaining a 1.8. About 3 weeks ago he started having severe pains in his knees, and the pain has got worse and moved up his legs to his hip joints. Prior to the transplant he was a PD dialysis patient, and then 4 months prior to the operation he went to hem dialysis. During his dialysis treatment time, his phosphorus levels always ran high. Is it possible that his current pain is due to calcium being depletion from his bones during dialysis or is a side effect of the medicine? Also, his Uric arid is 7.9, WBC is 11.4, and the alkaline phosphates is 295. To the best of our knowledge there was not any blood transfusions during his surgery, and the kidney was a living donor, and the donor does not have any liver problems.

A:You are describing what appears to be Migratory Polyarthritis in two and half months post transplant recipient. There could be a variety of causes responsible for such presentation so early in the transplant. Since he is in maximum state of immunosuppression, infectious causes would remain on the top of list. In a review of the University of Pennsylvania renal transplant experience, such form of arthritis was caused by bacteria in 66% of cases (half of which were caused by S. aureus), mycobacteria (tuberculosis) in 17%, and disseminated cytomegalovirus infection in 17%. Rarely fungus can be the culprit as well. With the current ubiquitous use of Prograf/cyclosporine, gouty arthritis (occasionally polyarticular with atypical joint involvement) is extremely common and may mimic septic arthritis. Even though, uric acid is reportedly normal, it does not entirely exclude gout. Since the cause of renal failure is not mentioned, other possible causes may include recurrence of the original disease vasculitis, familial Mediterranean fever, crohn's disease etc. It is advisable that transplant nephrologist be consulted, proper examination and imaging of the affected joints be performed and if there is any effusion, a diagnostic tap be performed to establish diagnosis.

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