Gutiérrez de la Fuente C, Sola E, Alférez M J, Navarro A, Cabello M, Burgos D, González Molina M
Servicio de Nefrología, Hospital Carlos Haya, Málaga.
Nefrologia. 2004;24 Suppl 3:3-6.
Among the numeruos adverse side effects of tacrolimus (TAC), de novo thrombotic microangiopathy stands out as an infrecuente but severe complication. Renal dysfunction is the only alteration that should lead to suspicion of thrombotic microangiopathy, because the clinical features of intravascular hemolysis are not always found. The definitive diagnosis can usually be made with kidney biopsy. Patientes with TAC induced thrombotic microangiopathy usually promptly recover after treatment withdrawal or reduction in the dose of TAC and a short course of plasma therapy, but the risk of rejection increases. Switching from TAC to cyclosporine has also been tried with resolution of the hemolysis but thrombotic microangiopathy has been noted with both and this condition may later recur. We present a 29-year-old man who received a kidney-pancreas transplant for end-stage diabetic nephropathy. After initial induction with basiliximab, the immunosuppression consisted of prednisone, tacrolimus and mycophenolate mofetil. Twenty four days posttransplantation his renal function declined with a peak creatine level of 2.35 mg/dl. Laboratory studies showed thrombocytopenia and features of intravascular hemolysis. TAC associated hemolytic uremic syndrome was suspected and drug was immediately stopped and converted to sirolimus. Also he was treated with plasma infusion. The allograft biopsy showed focal glomerular and arteriolar acute thrombosis without evidence of rejection. Our experience demostrate that switching from tacrolimus to sirolimus could be an adecuate strategy for patients who develop FK506-associated de novo thrombotic microangiopathy without increase risk of acute rejection.
在他克莫司（TAC）众多的不良反应中，新发血栓性微血管病是一种罕见但严重的并发症。肾功能障碍是唯一应引起对血栓性微血管病怀疑的改变，因为血管内溶血的临床特征并不总是能发现。通常通过肾活检做出明确诊断。TAC诱导的血栓性微血管病患者在停药或减少TAC剂量并进行短期血浆治疗后通常能迅速康复，但排斥反应的风险会增加。也有人尝试将TAC换成环孢素，溶血得到缓解，但两种药物都出现了血栓性微血管病，且这种情况可能会复发。我们报告一名29岁男性，因终末期糖尿病肾病接受了肾胰联合移植。在最初使用巴利昔单抗诱导后，免疫抑制方案包括泼尼松、他克莫司和霉酚酸酯。移植后24天，他的肾功能下降，肌酐水平峰值达到2.35mg/dl。实验室检查显示血小板减少和血管内溶血特征。怀疑为TAC相关的溶血性尿毒症综合征，立即停药并换成西罗莫司。同时对他进行了血浆输注治疗。移植肾活检显示局灶性肾小球和小动脉急性血栓形成，无排斥反应证据。我们的经验表明，对于发生FK506相关新发血栓性微血管病的患者，从他克莫司换成西罗莫司可能是一种合适的策略，且不会增加急性排斥反应的风险。
