Introduction:
Tacrolimus has become the preferred maintenance immunosuppressive drug for prevention of allograft rejection in kidney transplants over the last two decades. Tacrolimus Induced Thrombotic Microangiopathy (TMA) is a rare yet serious complication which can occur in patients in the immediate post transplantation period.It has a huge impact on short term and long term graft survival.
Methods:
In this case series, we studied four patients who underwent kidney transplants in Mumbai from 2023-2024 and were diagnosed with Tacrolimus induced TMA, within a short span post kidney transplant. We assessed their clinical course and reviewed all their laboratory data, investigations snd treatment options offered to prevent allograft loss .
Results:
The median age at transplant of the 4 patients was 33 years. The median onset of Tacrolimus induced TMA was 4.5 days post transplantation. 3 patients received kidneys from living donors whereas 1 patient received a kidney from a deceased donor, and were at a low immunological risk at there time of transplantation . All 4 patients received induction with Antithymocyte Globulin and Methylprednisolone at standard dosages. All four patients experienced early graft dysfunction post transplant with median serum creatinine being 4.95 mg/dL on day 5 after transplant . 2 out of the 4 patients had anaemia ,thrombocytopenia , raised LDH and reticulocyte counts. 1 patient had a hypertensive urgency , an episode of generalized tonic clonic seizure and posterior reversible encephalopathy (PRES) diagnosed on MRI Brain . Median Tacrolimus Levels in the 4 patients was 8.8 ng/mL on the day of the kidney biopsy .Tacrolimus was withheld in all patients . 3 out 4 patients underwent plasma exchange (3-5 sessions each). On biopsy, there was presence of fibrin thrombi within the glomeruli, C4d was found to be negative, confirming TMA . On discontinuation of Tacrolimus , renal function improved with median serum creatinine being 2.95 mg/dL after 2 weeks of diagnosis . 2 out of 4 patients were continued on dual immunosuppressants (MMF and steroids), 1 patient was started on Sirolimus and 1 patient was started on Belatacept, all of which lead to stabilization in renal allograft function.Non of these patients were switched to Cyclosporine . There was no associated mortality at 1 year post transplantation.
Conclusions:
High index of suspicion and confirmation of Tacrolimus induced TMA, prompt discontinuation of Tacrolimus and early plasmapheresis can prevent graft loss in these patients in the early post transplant period . Switching to alternative therapeutic options such as Sirolimus/Belatacept should be considered.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.