Looking Beyond Common Causes of Renal Dysfunction: Renal GVHD and Thrombotic Microangiopathy after Allogeneic Transplant

Renal dysfunction after allogeneic hematopoietic stem cell transplantation (allo-HSCT) often results from common causes like drug toxicity, infection, or transplant-associated thrombotic microangiopathy (TA-TMA). However, renal graft-versus-host disease (GVHD) may be ignored. We discuss a 49-year-old man who experienced worsening kidney function despite being in hematologic remission and having negative results for infections and autoimmune diseases. A renal biopsy showed chronic tubulointerstitial injury consistent with renal GVHD, along with existing TMA. Treatment with eculizumab did not lead to improvement, likely indicating significant chronic damage. This case highlights the need to maintain clinical suspicion and to perform timely renal biopsies in cases of unexplained kidney dysfunction after transplant.