Böbrek Nakli Sonrası İskemik Kolit ile Prezente olan Tacrolimus İlişkili Trombotik Mikroanjiyopati: Bir Olgu Sunumu
Abstract
Kalsinörin inhibitörleri (KNİ), böbrek transplantasyonu sonrası immünosupresif rejimin önemli bir üyesidir. KNİ'ler bazı sitokinlerin gen transkripsiyonunu inhibe ederek, T hücre aktivasyonunu baskılar. Böbrek transplantasyonu yapılan hastaların çoğunda takrolimus tercih edilmektedir. Trombotik mikroanjiyopati (TMA), KNİ tedavisinin ciddi fakat nadir görülen bir komplikasyonudur. TMA, mikrovasküler tromboza yol açan arteriyollerin ve kapillerlerin spesifik bir patolojik lezyonunu tanımlar. Olgumuz, 45 yaşında erkek hasta olup otozomal dominant polikistik böbrek hastalığı (ODPKBH) nedeniyle beş ay önce böbrek transplantasyonu olmuştur. İdame immünosüpresif tedavisi takrolimus içermektedir. Nakil sonrası beşinci ayda karın ağrısı ve kanlı ishal şikayeti oluşmuş. Yapılan kolonoskopide çıkan kolonun mukozası ödematöz ve eritematöz olarak saptandı. Biyopsi örneklerinin incelemesinde lamina propriyadaki damar lümeni içindeki mikrotrombüs odakları gösterildi. Abdominal bilgisayarlı tomografi (BT) anjiyografi ile vasküler tromboz veya tıkanıklık araştırılıp dışlanmıştır. Bakılan periferik yaymada, şistositler ve ılımlı derecede trombositopeni izlenildi. Klinik, laboratuvar ve histolojik bulgular ışığında TMA tanısı konuldu. Takrolimus patolojik sürecin tetikleyicisi olarak değerlendirildi, hızlıca everolimus ile değiştirildi. Daha sonra laboratuvar anormallikleri ve klinik semptomlar düzeldi. Biz bu olgu sunumunda; ilaca bağlı TMA ve kolonun mikrovasküler gibi atipik tutulum lokalizasyonuna dikkat çekmeyi amaçladık.
References
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- Webster AC, Woodroffe RC, Taylor RS, Chapman JR, Craig JC. Tacrolimus versus ciclosporin as primary immunosuppression for kidney transplant recipients: meta-analysis and meta-regression of randomised trial data. BMJ 2005; 331(7520):810.
- George JN, Nester CM. Syndromes of Thrombotic Microangiopathy. New England Journal of Medicine 2014; 371(7):654-66.
- Toriu N, Sekine A, Mizuno H, Hasegawa E, Yamanouchi M, Hiramatsu R, et al. Renal-limited thrombotic microangiopathy due to bevacizumab therapy for metastatic colorectal cancer: a case report. Case Reports in Oncology 2019; 12(2):391-400.
- Brocklebank V, Wood KM, Kavanagh D. Thrombotic microangiopathy and the kidney. Clinical Journal of the American Society of Nephrology 2018; 13(2):300-17.
- Riedl M, Fakhouri F, Le Quintrec M, Noone DG, Jungraithmayr TC, Fremeaux-Bacchi V, et al. Spectrum of complement-mediated thrombotic microangiopathies: pathogenetic insights identifying novel treatment approaches. Seminars in Thrombosis and Hemostasis 2014; 40(4):444-64.
- Kathula SK, Koduri J, Mall S, Chang JC. A case report of total abdominal hysterectomy resulting in acute thrombotic thrombocytopenic purpura with pancreatitis and hepatitis: complete resolution with plasma exchange therapy. Therapeutic Apheresis and Dialysis 2003; 7(3):373-4.
- Smirnova T, Kozlovskaya N, Sheludchenko V. Ocular manifestations of primary thrombotic microangiopathy. Vestnik Oftalmologii 2021; 137(5):138-44.
- Dubois A, Lyonnet P, Cohendy R, Said HO, Branger B, Raffanel C, et al. Ischemic colitis as a manifestation of Moschkowitz's syndrome. In: Annales de Gastroenterologie et d'Hepatologie: 1989; 1989: 19.
- See JR, Sabagh T, Barde CJ. Thrombotic thrombocytopenic purpura: a case presenting with acute ischemic colitis. Case Reports in Hematology 2013; 2013:592930.
- Oglat A, Quigley EM. Colonic ischemia: usual and unusual presentations and their management. Current Opinion in Gastroenterology 2017; 33(1):34-40.
- Tadros M, Majumder S, Birk JW. A review of ischemic colitis: is our clinical recognition and management adequate? Expert Review of Gastroenterology & Hepatology 2013; 7(7):605-13.
- Staatz CE, Tett SE. Clinical pharmacokinetics and pharmacodynamics of tacrolimus in solid organ transplantation. Clinical Pharmacokinetics 2004; 43(10):623-53.
- Chatzikonstantinou T, Gavriilaki M, Anagnostopoulos A, Gavriilaki E. An update in drug-induced thrombotic microangiopathy. Frontiers in Medicine 2020; 7:212.
- Nwaba A, MacQuillan G, Adams LA, Garas G, Delriviere L, Augustson B, et al. Tacrolimus-induced thrombotic microangiopathy in orthotopic liver transplant patients: case series of four patients. Internal Medicine Journal 2013; 43(3):328-33.
Tacrolimus-Associated Thrombotic Microangiopathy Presenting with Ischemic Colitis After Kidney Transplantation: A Case Report
Abstract
Calcineurin inhibitors (CNIs) are a significant component of the immunosuppressive regimen after kidney transplantation. By inhibiting cytokine gene transcription, CNIs suppress T cell and T cell-dependent B cell activation. Tacrolimus is preferred in most patients undergoing kidney transplantation. Thrombotic microangiopathy (TMA) is a severe but rare complication of CNIs therapy. TMA defines a specific pathologic lesion of arterioles and capillaries that leads to microvascular thrombosis. A 45-year-old male underwent kidney transplantation five months ago due to autosomal dominant polycystic kidney disease (ADPKD). His triple-maintenance immunosuppressive therapy includes tacrolimus. Abdominal pain and bloody diarrhea occurred in the fifth month of posttransplant. The edematous and erythematous mucosa of the ascending colon was detected on the colonoscopy. The foci of microthrombi inside the vessel lumen in the lamina propria were shown biopsy. The thrombosis or occlusion was excluded with computerized tomography (CT) angiography in abdominal vessels. The fragmented red blood cells and moderate thrombocytopenia were detected on the peripheral blood smear. Eventually, TMA diagnosis was established through laboratory and histological findings. Tacrolimus was suspected as the trigger of the pathological process and promptly switched to the everolimus. Afterward, laboratory abnormalities and clinical symptoms were improved. In this case, we intend to emphasize drug-associated TMA and atypical presentations, such as colonic microvasculature involvement.
References
- Azzi JR, Sayegh MH, Mallat SG. Calcineurin inhibitors: 40 years later, can’t live without. The Journal of Immunology 2013; 191(12):5785-91.
- Webster AC, Woodroffe RC, Taylor RS, Chapman JR, Craig JC. Tacrolimus versus ciclosporin as primary immunosuppression for kidney transplant recipients: meta-analysis and meta-regression of randomised trial data. BMJ 2005; 331(7520):810.
- George JN, Nester CM. Syndromes of Thrombotic Microangiopathy. New England Journal of Medicine 2014; 371(7):654-66.
- Toriu N, Sekine A, Mizuno H, Hasegawa E, Yamanouchi M, Hiramatsu R, et al. Renal-limited thrombotic microangiopathy due to bevacizumab therapy for metastatic colorectal cancer: a case report. Case Reports in Oncology 2019; 12(2):391-400.
- Brocklebank V, Wood KM, Kavanagh D. Thrombotic microangiopathy and the kidney. Clinical Journal of the American Society of Nephrology 2018; 13(2):300-17.
- Riedl M, Fakhouri F, Le Quintrec M, Noone DG, Jungraithmayr TC, Fremeaux-Bacchi V, et al. Spectrum of complement-mediated thrombotic microangiopathies: pathogenetic insights identifying novel treatment approaches. Seminars in Thrombosis and Hemostasis 2014; 40(4):444-64.
- Kathula SK, Koduri J, Mall S, Chang JC. A case report of total abdominal hysterectomy resulting in acute thrombotic thrombocytopenic purpura with pancreatitis and hepatitis: complete resolution with plasma exchange therapy. Therapeutic Apheresis and Dialysis 2003; 7(3):373-4.
- Smirnova T, Kozlovskaya N, Sheludchenko V. Ocular manifestations of primary thrombotic microangiopathy. Vestnik Oftalmologii 2021; 137(5):138-44.
- Dubois A, Lyonnet P, Cohendy R, Said HO, Branger B, Raffanel C, et al. Ischemic colitis as a manifestation of Moschkowitz's syndrome. In: Annales de Gastroenterologie et d'Hepatologie: 1989; 1989: 19.
- See JR, Sabagh T, Barde CJ. Thrombotic thrombocytopenic purpura: a case presenting with acute ischemic colitis. Case Reports in Hematology 2013; 2013:592930.
- Oglat A, Quigley EM. Colonic ischemia: usual and unusual presentations and their management. Current Opinion in Gastroenterology 2017; 33(1):34-40.
- Tadros M, Majumder S, Birk JW. A review of ischemic colitis: is our clinical recognition and management adequate? Expert Review of Gastroenterology & Hepatology 2013; 7(7):605-13.
- Staatz CE, Tett SE. Clinical pharmacokinetics and pharmacodynamics of tacrolimus in solid organ transplantation. Clinical Pharmacokinetics 2004; 43(10):623-53.
- Chatzikonstantinou T, Gavriilaki M, Anagnostopoulos A, Gavriilaki E. An update in drug-induced thrombotic microangiopathy. Frontiers in Medicine 2020; 7:212.
- Nwaba A, MacQuillan G, Adams LA, Garas G, Delriviere L, Augustson B, et al. Tacrolimus-induced thrombotic microangiopathy in orthotopic liver transplant patients: case series of four patients. Internal Medicine Journal 2013; 43(3):328-33.
Details
| Primary Language | English |
|---|---|
| Subjects | Health Care Administration |
| Journal Section | Olgu Sunumları |
| Authors | |
| Early Pub Date | March 28, 2024 |
| Publication Date | March 28, 2024 |
| Submission Date | December 18, 2022 |
| Acceptance Date | March 14, 2023 |
| Published in Issue | Year 2024 Volume: 19 Issue: 1 |
