Simultaneous Renal Transplantation and Splenectomy: Double Strike?

We present a 59 year-old female suffering from idiopathic thrombocytopenic purpura and end stage renal disease due to mesangiocapillary (Type III) glomerulonephritis, who received a kidney transplant from a living unrelated male donor. Aiming for a definite and durable management for idiopathic thrombocytopenic purpura and because of calcified pelvic vessels, she had simultaneous splenectomy and left orthotopic renal transplantation after only pulse-steroid induction. Post-transplant immunosuppression comprised tacrolimus, mycophenolic acid and prednisolone. Graft functioned well, apart from transient rise of serum creatinine after few days due to tacrolimus induced thrombotic microangiopathy. The offending drug was withdrawn under cover of 2 doses of basiliximab. The patient achieved normal kidney function thereafter and cyclosporine was introduced instead of tacrolimus. Unfortunately, she experienced a chain of infections caused by different bacterial and fungal infections, starting with superficial wound infection and followed by urinary tract infection and septicemia, which turned out to be superimposed on cytomegaloviral (CMV) activation. Lowering immunosuppressive drug doses, antiviral treatment and culture-based antibiotics failed to control these infections, leading to the patient's death with a functioning graft, 1 month after transplantation. Conclusion: despite surgically feasible, simultaneous splenectomy and renal transplantation may carry the risk of over immunosuppression and potentially fatal infection.