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F.S.L, male, 48 years old, hypertensive, obese, evolved with Diabetes-related kidney disease stage 5. The patient underwent hemodialysis for 2 years until he received a deceased donor kidney transplant (TxR) on February 7, 2018. Received induction with antithymocyte globulin 5.5 mg/kg and maintenance therapy with tacrolimus and mycophenolate (MPA). After transplantation, experienced recurrent secondary infection (IgG D+/R+) by cytomegalovirus (CMV), and was switched from MPA to everolimus (EVR) 3 months post TxR, achieving viremia control. In 2020, everolimus (EVR) was switched to sirolimus (SRL) due to logistical reasons at the center. In October 2022, the patient developed an edematogenic syndrome. At admission, the patient didn’t present nephrotic proteinuria.
Case collected at Hospital Universitario Walter Cantidio (HUWC). The patient underwent a renal transplant and subsequently developed pericardial effusion. This situation prompted the collection of tests to determine the cause of this complication.
The investigation revealed a significant pericardial effusion, leading to heart failure. Intraoperatively, no pericardial thickening was observed. The fluid had a cloudy appearance and amber color, with a volume of 55ml, and cytology was negative for neoplastic cell search. At the occasion, initially, the pericardial fluid's differential analysis yielded results of 2% lymphocytes, 28% mesothelial cells, and 71% macrophages. Subsequent tests, including culture for Mycobacterium tuberculosis, Gram-stained bacteria, fungi, ADA, and Genexpert, all returned with negative results. Subsequently, the patient discontinued the use of sirolimus and resumed mycophenolate without undergoing additional treatments. The patient progressed favorably, with no recurrence of symptoms and complete resolution of edema.
Sirolimus is an important medication to prevent acute rejection in patients who have undergone renal transplant procedures. Rare cases have been associated with pericardial effusion, but none described this purulent aspect of pericardial fluid. This complication is more often observed in patients who underwent cardiac transplants, but is considered rare in other types of transplant patients. In the presented case, following the surgical procedure and investigation of secondary causes for the effusion, as all possible metabolic or infectious etiologies were ruled out, the suspension of sirolimus, correlated with the patient's health improvement without recurrence of effusion or edema, acted as evidence of the adverse side effect of the immunosuppressive medication. It is worth highlighting the atypical appearance of the collected fluid, which differed with its cloudy and amber color from the typically observed citrine appearance. The use of mTOR inhibitors, such as Sirolimus, remains of significant importance in the case of transplant patients. Given their potential side effects, although rare in some cases, it is crucial to consider the risks before choosing them for patient treatment. Thus, their use after renal transplantation requires continuous monitoring, dosage management, and adjustments to the treatment regimen if necessary.