Objective:

To report a case of renal cell carcinoma (RCC) in a failed kidney allograft presenting with spontaneous cyst rupture and hemorrhage, followed by identification of RCC in the native kidney, and to describe a gap in surveillance guidance for patients awaiting retransplantation.

Approach:

• Case: A 53-year-old woman with acquired cystic kidney disease and a failed kidney allograft had resumed hemodialysis three years before presenting with acute abdominal pain, leukocytosis, and falling hemoglobin.
• Evaluation and treatment: Imaging showed an enlarged, cystic transplant kidney and retroperitoneal fluid. Persistent severe pain and a hemoglobin decline led to transplant nephrectomy on hospital day four.
• Follow-up: Two years later, during retransplantation assessment, right native nephrectomy for a suspicious mass identified a second RCC. She remained inactive on the transplant waiting list and continued to require hospitalizations for sepsis.

Key Findings:

• The allograft contained 10 tumors: acquired cystic disease–associated RCC and clear cell tubulopapillary RCC, with grades ranging from 1 to 3 and no vascular invasion.
• The allograft contained a ruptured cyst surrounded by substantial hematoma; graft cultures grew Candida albicans/dubliniensis.
• Follow-up imaging showed no distant metastasis.
• The native kidney tumor was eosinophilic solid and cystic RCC.
• The patient remained inactive on the transplant waiting list and continued to require hospitalizations for sepsis.

Interpretation:

To the authors’ knowledge, this is the first reported case of de novo RCC in a kidney allograft presenting with cyst rupture and hemorrhage. RCC was also identified in the native kidney two years later. The authors note a gap in guidance on malignancy surveillance for patients with graft failure awaiting retransplantation.

Limitations:

• This is a single case report and cannot establish the frequency of this presentation or the effectiveness of screening.
• The article notes that randomized controlled trials evaluating RCC screening benefits are lacking.

Conclusion:

This case describes RCC in a failed kidney allograft presenting with spontaneous cyst rupture, hemorrhage, and fungal infection, followed two years later by RCC in the native kidney. The authors identify a gap in guidance on malignancy surveillance for patients with graft failure awaiting retransplantation.

Sources:

• Article context provided