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von Brünn Nests Hyperplasia as a Cause of Ureteral Stenosis After Kidney Transplantation
Mouad Hamzaoui, Arnaud François, Guillaume Defortescu, Isabelle Etienne, Charlotte Laurent, Dominique Bertrand, Dominique Guerrot
To cite this version:
Mouad Hamzaoui, Arnaud François, Guillaume Defortescu, Isabelle Etienne, Charlotte Laurent, et al..
von Brünn Nests Hyperplasia as a Cause of Ureteral Stenosis After Kidney Transplantation. Kidney
International Reports, Elsevier, 2017, 2 (3), pp.498-501. �10.1016/j.ekir.2016.11.008�. �hal-02316772�
Von Brünn Nests Hyperplasia as a Cause of Ureteral Stenosis After Kidney
Transplantation
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Mouad Hamzaoui
1,4, Arnaud Francois
2, Guillaume Defortescu
3, Isabelle Etienne
1, Charlotte Laurent
1, Dominique Bertrand
1and Dominique Guerrot
1,41Service de Néphrologie, CHU Hôpitaux de Rouen, Rouen, France; 2Service d’Anatomie Pathologique, CHU Hôpitaux de Rouen, Rouen, France;3Service d’Urologie, CHU Hôpitaux de Rouen, Rouen, France; and4INSERM Unité 1096, Université de Médecine-Pharmacie de Rouen, Rouen, France
Correspondence:Dominique Guerrot, Service de Néphrologie–CHU Hôpitaux de Rouen, 1 rue de Germont, 76031 Rouen Cedex, Rouen, France. E-mail:dominique.guerrot@chu-rouen.fr
Kidney Int Rep(2016)-,-–-;http://dx.doi.org/10.1016/j.ekir.2016.11.008
ª2016 International Society of Nephrology. Published by Elsevier Inc. This is an open access article under the CC BY- NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
INTRODUCTION
U rologic complications occur in 2.5% to 20% of patients after kidney transplantation, and are an important cause of allograft loss and patient morbidity.1–6 The most frequent technical adverse events stem from complications of the ureterovesical anastomosis, including urinary fistulae, and stenosis.
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An intrinsic ureteral stricture can also occur as a consequence of local inflammation, infection, or inad- equate vascularization resulting in ischemia of the ureteral transplant.
1,6
Von Brünn nests are considered as a variant of the normal urinary tract histology, and originate from the proliferation of benign urothelial cells within the lam- ina propria.
7–9This particular structure develops mainly in the bladder, but can also be found in the ureters. To date, von Brünn nests have not been described as a potential cause of ureteral stenosis.
Here, we report the first case
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of posttransplantation
obstructive kidney failure due to the hyperplasia of ureteral von Brünn nests, analyze the origin of the proliferating cells, and discuss pathophysiological mechanisms and potential clinical implications.
CASE PRESENTATION
A 63-year-old man with end-stage kidney disease due to IgA nephropathy received a kidney transplant from a deceased donor. Computed tomography performed in the 60-year-old female donor had revealed no specific anomaly of the kidneys or of the urinary tract. During the preparation of the allograft, the macroscopic appearances of the kidney and the ureter were unre- markable. The kidney was implanted in the left iliac
fossa. A double J stent was used for the ureteric reimplantation, and no significant issue was noted during the surgical procedure. The cold and warm ischemia times were 8 hours and 65 minutes, respec- tively. The standardized immunosuppressive regimen prescribed to the patient included basiliximab and methylprednisolone pulses as the induction treatment, followed by the association of tacrolimus, mycophe-
Q3nolate mofetil, and prednisolone. The postoperative outcome was favorable. No infection was recorded.
Plasma creatinine was 1.3 mg/dl 14 days after trans- plantation and remained stable until the double J stent was removed 4 weeks later, in accordance with the local protocol.
Three months after the removal of the double J stent, the patient’s plasma creatinine increased from 1.3 to 1.8 mg/dl within 3 weeks. A urinary tract ultra- sound was performed, and showed a large, 28-mm dilatation of the allograft pelvis. This dilatation was confirmed by a computed tomography scan (Figure 1).
The radiological appearance suggested that the stenosis was located mainly in the very proximal part of the ureter below the pelviureteral junction, mimicking a pyeloureteral junction syndrome. A furosemide
99m
Tc-MAG3 scintigraphy revealed slow clearance of pelvicalyceal and ureteral activity in the allograft, consistent with a pathophysiological significance of the obstruction. The decision was taken to perform a pyeloureteral anastomosis with the left native ureter, and to resect the donor ureter for histological analysis.
The patient initially refused the urological manage- ment, and neither temporary stent placement nor retrograde ureteropyelography was performed in this context. The follow-up showed persistent 1 2
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hydronephrosis. Plasma creatinine progressively increased, up to 2.3 mg/dl when the pyeloureteral anastomosis was finally performed 3 months after the diagnosis.
After surgery, plasma creatinine decreased to 1.4 mg/dl. Pathological analysis of the ureteral allograft (pyeloureteral junction and a 3-cm-long fragment of the proximal ureter) revealed a multifocal narrowing of the lumen due to a florid circumferential hyperplasia of von Brünn nests strictly limited to the lamina propria, within the ureteral wall (Figure 2).
No atypia was present, and SV40 staining was negative. To determine whether the von Brünn nests stemmed from the donor or whether they were a retrograde proliferation originating from the recipient’s bladder, we took advantage of the sex difference be- tween the 2 subjects. We performed a fluorescence in situ hybridization (FISH) with CEP “X” and “Y”
probes (DXZ1 and DYZ3, Vysis kit, Abbott, France ) on
Q4both the allograft ureter and on a biopsy of the prox- imal left native ureter. External controls were satis- factory. The internal control (native ureter) presented a characteristic “XY” phenotype, as expected. We found a double “XX” fluorescence within the von Brünn nests, confirming the donor origin (Figure 3). Over an 18-month follow-up, plasma creatinine was stable, and no recurrence or additional urological complication was noted.
DISCUSSION
Von Brünn nests are benign proliferative and meta- plastic lesions of the urinary tract. They are caused by the invagination of overlying urothelial cells, which aggregate into round nests within the superficial lam- ina propria.
7,9,10Their most frequent location is the bladder trigone and the submucosa of the pelviureteral junction. This specific histological condition can be highly prevalent, with autopsy series revealing that up to 90% of bladders present with von Brünn nests.
9Von Brünn nests are usually devoid of atypia; however, they can undergo hyperplasia and become visible on bladder cystoscopy as pink or white submucosal blebs.
More rarely, they can undergo central cystic degener- ation (cystitis cystica), or atypical glandular differ- enciation (cystitis glandularis) and become visible on ultrasound.
7,11,12The main differential diagnosis is nested cell urothelial carcinoma.
12–14This diagnosis can be excluded in our patient because of the focal locali- zation limited to the lamina propria, the absence of cellular atypia, and the favorable evolution. In rare cases, von Brünn nests can lead to obstruction of the cystic outlet or of the ureterovesical junction, after cystic degeneration.
8,10,11To the best of our knowledge, hyperplasia of von Brünn nests has not been described as a potential cause of ureteral stenosis below the pelviureteral junction, and no urological complication related to von Brünn nests in solid organ transplant recipients has been previously reported. In our case, after careful reviewing of the clinical, laboratory, radiologic, per- operative, and pathological data, no argument for an alternative ischemic, infectious, neoplastic, or me- chanical cause of this incomplete ureteral stenosis was found. Because of the artifactual increase in the lumen diameter due to fixation, the photograph shown in
Figure 1. Computed tomography scanner. Pyelocalyceal dilation and dilation of the proximal ureter.
web4C=FPO
Figure 2. Histological analysis of the proximal part of the allograft ureter. Hyperplasia of von Brünn nests, characterized by multifocal proliferation in the lamina propria, devoid of cellular atypia. Hematox- ylin and eosin safran staining. Original magnification (a)10, (b)40.
NEPHROLOGY ROUNDS M Hamzaoui et al.: Ureteral von Brünn Hyperplasia After Kidney TransplantationQ1
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Figure 2 most likely underestimates the narrowing of the ureteral lumen present in vivo. In addition, the blood flow, edema, and contraction of the ureteral smooth muscle cells are dynamic factors that further decrease the diameter of the lumen, whereas they are totally absent when evaluated on pathological material.
In kidney transplant recipients, proliferative lesions of the urinary tract can originate from local or meta- plastic growth of recipient cells or of donor-transmitted cells, as is the case in nephrogenic adenoma.
15Here, using fluorescence in situ hybridization, we demon- strated that the ureteral obstruction was the direct consequence of local hyperplasia of donor-transmitted cells. Importantly, the donor’s initial CT scan was unremarkable, and the contralateral kidney presented with no pyelocalyceal dilatation 6 months after trans- plantation in the other recipient, which suggests that specific factors in our patient triggered post- transplantation hyperplasia of the preexisting von Brünn nests.
Pathophysiological mechanisms leading to hyperpla- sia of von Brünn nests have been poorly studied, but are believed to include ischemia, infection, inflamma- tion, chemotherapy, and radiotherapy.
7,9–11,16,17One study has shown that cells of von Brünn nests synthesize and express fibroblast growth factor (FGF) 10 receptor, and that a paracrine synthesis of FGF-10 is present in the vicinity of von Brünn nests in the exstrophic bladder.
18FGF-related signaling could therefore be a key factor in the proliferation of von Brünn nests.
19Vin- sonneau et al. have demonstrated that urothelial prolif- eration happens following ischemic injury, and, interestingly, that this event is dependent on fibroblast growth factor signaling.
20In this context, we speculate that the transplantation-related ischemia contributed to the hyperplasia of the preexisting von Brünn nests in our patient. In addition, although no infection was recorded during the posttransplantation period, the insertion of the double J stent and its presence during 4 weeks may have induced and sustained local inflammation.
web4C=FPO
Figure 3. Fluorescencein situhybridization of (a) the allograftand (b) the native ureters. The X chromosome is revealed by the green probe andQ8 the Y chromosome by the red probe. (a) Von Brünn nests exclusively present X probes in the allograft ureter, which demonstrates that the proliferation originates from the donor. (b) As expected, in the recipient’s native ureter, X and Y probes were expressed together.
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No specific management has been suggested for von Brünn nest hyperplasia, except for the treatment of potential inducing factors. This is most likely because of the benign nature of the proliferation and the rarity of complications. In our case, the diagnosis was not suspected before the results of the histological analysis.
Whether the proliferation and the chronic obstruction could have been improved with an alternative medical management, for example with high-dose corticoste- roids, is uncertain.
16No spontaneous improvement was observed, although the patient decided to postpone the surgery. Ultimately, the pyeloureteral anastomosis offered a definitive treatment.
In conclusion, this case presents an unusual and potentially underestimated cause of obstructive decrease in kidney function after transplantation.
Awareness of this condition can be useful for ne- phrologists, urologists, radiologists, and pathologists involved in the care of solid organ transplant recipients.
DISCLOSURE
All the authors declared no competing interests.
ACKNOWLEDGMENTS
The authors thank Carole Basset and Dr. Maxime Arnaud (Pathology Department, Rouen University Hospital, Rouen, France) for their technical assistance, and Dr. Géraldine Joly-Helas (Department of Genetics, Rouen University Hospital, Rouen, France) for kindly providing the probes for thefluorescencein situhybridization.
SUPPLEMENTARY MATERIAL
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Figure S1.---
Supplementary material is linked to the online version of the paper atwww.kireports.org.
REFERENCES
1. Palazzetti A, Oderda M, Dalmasso E, et al. Urological conse- quences following renal transplantation: a review of the literature.Urologia. 2015;82:211–218.
2. Nie ZL, Zhang KQ, Li QS, et al. Urological complications in 1, 223 kidney transplantations.Urol Int. 2009;83:337–341.
3. Pisani F, Iaria G, D’Angelo M, et al. Urologic complications in kidney transplantation.Transplant Proc. 2005;37:2521–2522.
4. Kocak T, Nane I, Ander H, et al. Urological and surgical complications in 362 consecutive living related donor kidney transplantations.Urol Int. 2004;72:252–256.
5. Hussain M, Khalique M, Askari H, et al. Surgical compli- cations after renal transplantation in a living-related transplantation program at SIUT. Transplant Proc.
1999;31:3211.
6. Makisalo H, Eklund B, Salmela K, et al. Urological complica- tions after 2084 consecutive kidney transplantations.Trans- plant Proc. 1997;29:152–153.
7. Erturk E, Sheinfeld J, Davis RS. Metaplastic cystitis compli- cated with Von Brunn nests, cystitis cystica, and intestinal type of glandular metaplasia.Urology. 1988;32:165–167.
8. Franco I, Eshghi M, Schutte H, et al. Bladder neck obstruction secondary to Brunn’s cyst.J Urol. 1988;139:126–127.
9. Wiener DP, Koss LG, Sablay B, Freed SZ. The prevalence and significance of Brunn’s nests, cystitis cystica and squamous metaplasia in normal bladders.J Urol. 1979;122:
317–321.
10. Sailo SL, Sailo L. Brunn’s cyst: a rare cause of bladder outlet obstruction in a young man.Urol J. 2015;12:2381.
11. Grimsby GM, Tyson MD, Salevitz B, et al. Bladder outlet obstruction secondary to a Brunn’s cyst.Curr Urol. 2012;6:
50–52.
12. Volmar KE, Chan TY, De Marzo AM, Epstein JI. Florid von Brunn nests mimicking urothelial carcinoma: a morphologic and immunohistochemical comparison to the nested variant of urothelial carcinoma. Am J Surg Pathol. 2003;27:
1243–1252.
13. Venyo AK. Nested variant of urothelial carcinoma.Adv Urol.
2014;192720. Q7
14. Pusztaszeri M, Hauser J, Iselin C, et al. Urothelial carcinoma
“nested variant”of renal pelvis and ureter.Urology. 2007;69, 778.e715–777.
15. Mazal PR, Schaufler R, Altenhuber-Muller R, et al. Deriva- tion of nephrogenic adenomas from renal tubular cells in kidney-transplant recipients. N Engl J Med. 2002;347:
653–659.
16. Yuksel OH, Urkmez A, Erdogru T, Verit A. The role of steroid treatment in intractable cystitis glandularis: a case report and literature review.Can Urol Assoc J. 2015;9:E306–E309.
17. Liu X, Chen Z, Ye Z. Etiological study on cystitis glandularis caused by bacterial infection.J Huazhong Univ Sci Technolog Med Sci. 2007;27:678–680.
18. Eastman R Jr., Leaf EM, Zhang D, et al. Fibroblast growth factor-10 signals development of von Brunn’s nests in the exstrophic bladder. Am J Physiol Renal Physiol. 2010;299:
F1094–F1110.
19. Walker KA, Sims-Lucas S, Bates CM. Fibroblast growth factor receptor signaling in kidney and lower urinary tract devel-
opment.Pediatr Nephrol. 2015. Q6
20. Vinsonneau C, Girshovich A, M’Rad MB, et al. Intrarenal urothelium proliferation: an unexpected early event following ischemic injury. Am J Physiol Renal Physiol. 2010;299:
F479–F486.
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