Reactions Weekly | 2021
Ciclosporin/mycophenolate-mofetil/tacrolimus
Abstract
Acute kidney injury and nausea: case report A 21-year-old man developed acute kidney injury during treatment with ciclosporin and tacrolimus. Additionally, he developed nausea during treatment with mycophenolate mofetil [routes and duration of treatments to reaction onset not stated; not all outcome stated]. The man, whose medical history was notable for nephrotic syndrome (NS) secondary to minimal change disease, developed a right middle cerebral artery territory infarct secondary to ischemic stroke. He was admitted to the hospital 6 months prior to stroke with generalized body swelling and shortness of breath for 1 month. Subsequent clinical examination revealed anasarca. Based on the laboratory investigation, he was diagnosed with NS. Due to fluid overload and worsening of kidney function, he had received temporary haemodialysis alternate with ultrafiltration for 6 weeks duration. He started receiving IV prednisolone 80 mg/day, furosemide 80mg three times per day and ciclosporin [cyclosporine] 25mg twice per day. At the second month of treatment, his kidney function improved with the creatinine level of 97 μmol/L and urea of 9.9 mmol/L. Haemodialysis was stopped. Subsequent biopsy revealed minimal change disease. Hence, his medications were switched to furosemide 40mg once per day, prednisolone tapering dose to 20mg once per day and ciclosporin 50mg twice per day. At the fourth month of treatment, his kidney function further deteriorated with the serum creatinine level of 264 μmol/L and urea of 9.0 mmol/L. He was admitted and reassessed. He did not respond to prednisolone and furosemide. The man’s immunosuppressive therapy was changed from ciclosporin to mycophenolate-mofetil (MMF) 500mg twice per day due to deterioration of renal function. At the fifth month of treatment, he presented to the clinic due to mycophenolate mofetil induced nausea. Hence, mycophenolate mofetil was switched to tacrolimus 1g twice a day. At the sixth month of treatment, he presented to the hospital with left hemiparesis (current presentation). After 210 minutes from stroke, a plain CT scan of brain was performed which showed a normal result. He subsequently started receiving treatment with thrombolysis with alteplase. At 375 minutes post-stroke onset and 135 minutes post-rTPA thrombolysis, MRI and MRA brain scan was performed which showed right middle cerebral artery territory infarct and stenosis at distal M1 segment of the right middle cerebral artery. He subsequently underwent mechanical thrombectomy with partial recanalization of M2 segment of the right middle cerebral artery. After mechanical thrombectomy, his kidney function deteriorated (acute kidney injury), which was thought to be related to tacrolimus and ciclosporin. His serum creatinine level was 528 μmol/L. Thereafter, he was intubated for respiratory distress as he developed fluid overload. After intubation, he underwent haemodialysis and tracheostomy. Further workup revealed that he had concomitant antiphospholipid syndrome (APS) and NS. He started receving vitamin K antagonist anticoagulant. At 3 month post-stroke review, he continuously required haemodialysis therapy. Thereafter, a long term renal replacement therapy was initiated due to persistent deterioration of kidney function. His left upper limb power improved to 2/5, and left lower limb power was 4/5. After 6 months of stroke, his condition improved. However, he had slight disability due to stroke.