De novo tacrolimus ' associated hemolytic uremic syndrome after renal transplantation - Case report
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A CMV infection<span class="elsevierStyleSup">8</span> has been associated with both the novo and recurrent<span class="elsevierStyleSup">9 </span>forms of post-transplant HUS. Parvovirus B19 and polioma BK virus infection have also been associated with de novo HUS in renal transplant recipients.<span class="elsevierStyleSup">10-12</span></p><p class="elsevierStylePara">The authors describe the clinical case of a Caucasian male, 33 years old with a history of chronic kidney disease of unknown etiology, in hemodialysis for nearly 7 years, with past medical history of severe hypertension, severe hypertriglyceridemia and chronic pancreatitis. Family history was irrelevant.</p><p class="elsevierStylePara">In May 2010 he was underwent a renal transplantation with deceased kidney allograft (donor: man aged 23, suffered TCE) with CMV (D + / R +), HBV, HCV and HIV negative and with ABO compatibility. In the presence of low immunological risk situation with PRA 0% and with HLA 4:6 matches, he did not submitted to induction and began a immunosuppression regimen with mycophenolic acid (1440 mg/day), Tacrolimus LP (0.15mg/kg), methylprednisolone (8mg/kg) and adopting an initial maintenance scheme comprising mycophenolic acid (1440mg/day), LP tacrolimus (16mg) and prednisone (20mg/day).</p><p class="elsevierStylePara">Initial graft function was immediate, without surgical complications but with severe hypertension of difficult to control. Doppler renal graft was performed that excluded vascular complications and showed a normal resistance index.</p><p class="elsevierStylePara">The 2nd day postoperatively for 3rd day there was a deterioration of renal graft function (serum creatinine of 2.92 to 3.15mg/dL) associated with abrupt drop in platelet count (97,000 to 19.000/μL), drop in serum hemoglobin (10.4 to 7.6g/dL) and increase serum levels of lactate dehydrogenase (LDH 1485U/L) with tacrolimus plasma level of 10ng/mL. The Coombs test (direct and indirect) was negative, serum haptoglobin decreased and were found 3% of schistocytes in peripheral blood smear.</p><p class="elsevierStylePara">The survey of CMV, BK virus and parvovirus B19 in blood by P.C.R. were negative. It was found normal plasma activity of the ADAMTS13 in the absence of inhibitors. The autoimmunity study with anti-nuclear antibodies, anti-dsDNA and anti-cytoplasmic antibodies and antiphospholipid antibody were negative as well as was negative donor-specific antibody. In relation to severity of thrombocytopenia was not possible to perform biopsy of renal allograft.</p><p class="elsevierStylePara">The patient remained clinically well and without gastrointestinal or neurological changes. Given the evidence of worsening of renal function (acute dysfunction of renal allograft) associated with markers of intravascular hemolysis (nonimmune: Coombs direct and indirect negative) was established the diagnosis of <span class="elsevierStyleItalic">De novo</span> hemolytic uremic syndrome post-transplant, probably associated with tacrolimus.</p><p class="elsevierStylePara">We suspended tacrolimus and mycophenolic acid (by myelosuppressive effects) and was introduced everolimus on the 5<span class="elsevierStyleSup">th</span> day. We obtained improved of blood pressure control. Despite the attitudes adopted on the 9<span class="elsevierStyleSup">th</span> day maintained parameters hemolysis (6.6g Hb/dL, and 31,000/μL platelet LDH 926U/L) and worsening of graft function (7.24mg/dL) with diuresis maintained (Table 1). We decided to initiate daily plasmapheresis (D9 to D23) (1.5 x the plasma volume) with fresh frozen plasma inactivated. The patient remained without neurological disorders. After 14 sessions of plasmapheresis and 3 daily hemodialysis sessions (D9 to D12) we observed recovery of renal graft function accompanied by the disappearance of markers of hemolysis. At discharge date he had a serum creatinine of 2.39 mg/dL and 6 months after the level of seric creatinine was of 1.0mg/dL, with no evidence of recurrent HUS (without analytical signal of intravascular hemolysis).</p><p class="elsevierStylePara">There are no treatment guidelines for this entity. Among 29 patients with De novo post-transplant TMA, 80% recovered graft function after cyclosporine stop and plasma therapy.<span class="elsevierStyleSup">13</span> Our experience demonstrates that switching from tacrolimus to everolimus with plasmapheresis with fresh plasma proved be an adequate strategy for this situation without increased risk of acute rejection.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interest</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The authors declare that there is no conflict of interest associated with this manuscript.</p><p class="elsevierStylePara"><a href="grande/11793_16025_37614_en_t111793.jpg" class="elsevierStyleCrossRefs"><img src="11793_16025_37614_en_t111793.jpg" alt="Laboratorial evolution"></img></a></p><p class="elsevierStylePara">Table 1. Laboratorial evolution</p>" "tienePdf" => false "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11793_16025_37614_en_t111793.jpg" "Alto" => 945 "Ancho" => 1419 "Tamanyo" => 283053 ] ] "descripcion" => array:1 [ "en" => "Laboratorial evolution" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Pham PT, Peng A, Wilkinson AH, Gritsch HA, Lassman C, Pham PC, et al. Cyclosporine and tacrolimus associated thrombotic microangiopathy. Am J Kidney Dis 2000;(36):844-50." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Reynolds JC, Agodoa LY, Yuan CM, Abbott KC. Thrombotic microangiopathy after renal transplantation in the United States. Am J Kidney Dis 2003;(42):1058-68." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "English J, Evan A, Houghton DC, Bennett WM. Cyclosporine-induced acute renal dysfunction in the rat. Evidence of arteriolar vasoconstriction with preservation of tubular function. Transplantation 1987;(44):135-41." 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| 2019 September | 22 | 15 | 37 |
| 2019 August | 22 | 5 | 27 |
| 2019 July | 14 | 16 | 30 |
| 2019 June | 34 | 5 | 39 |
| 2019 May | 20 | 5 | 25 |
| 2019 April | 54 | 20 | 74 |
| 2019 March | 35 | 16 | 51 |
| 2019 February | 31 | 16 | 47 |
| 2019 January | 33 | 9 | 42 |
| 2018 December | 80 | 30 | 110 |
| 2018 November | 122 | 17 | 139 |
| 2018 October | 121 | 21 | 142 |
| 2018 September | 80 | 15 | 95 |
| 2018 August | 49 | 18 | 67 |
| 2018 July | 44 | 12 | 56 |
| 2018 June | 62 | 17 | 79 |
| 2018 May | 68 | 17 | 85 |
| 2018 April | 73 | 13 | 86 |
| 2018 March | 44 | 7 | 51 |
| 2018 February | 70 | 7 | 77 |
| 2018 January | 51 | 11 | 62 |
| 2017 December | 76 | 15 | 91 |
| 2017 November | 53 | 11 | 64 |
| 2017 October | 40 | 9 | 49 |
| 2017 September | 41 | 11 | 52 |
| 2017 August | 24 | 11 | 35 |
| 2017 July | 38 | 20 | 58 |
| 2017 June | 40 | 8 | 48 |
| 2017 May | 43 | 10 | 53 |
| 2017 April | 39 | 7 | 46 |
| 2017 March | 25 | 4 | 29 |
| 2017 February | 39 | 5 | 44 |
| 2017 January | 25 | 11 | 36 |
| 2016 December | 58 | 2 | 60 |
| 2016 November | 73 | 10 | 83 |
| 2016 October | 93 | 7 | 100 |
| 2016 September | 116 | 10 | 126 |
| 2016 August | 172 | 0 | 172 |
| 2016 July | 172 | 0 | 172 |
| 2016 June | 116 | 0 | 116 |
| 2016 May | 115 | 0 | 115 |
| 2016 April | 71 | 0 | 71 |
| 2016 March | 56 | 0 | 56 |
| 2016 February | 85 | 0 | 85 |
| 2016 January | 80 | 0 | 80 |
| 2015 December | 114 | 0 | 114 |
| 2015 November | 78 | 0 | 78 |
| 2015 October | 73 | 0 | 73 |
| 2015 September | 54 | 0 | 54 |
| 2015 August | 46 | 0 | 46 |
| 2015 July | 76 | 0 | 76 |
| 2015 June | 43 | 0 | 43 |
| 2015 May | 70 | 0 | 70 |
| 2015 April | 9 | 0 | 9 |
Show all
