Severe tubulopathy and kidney graft rupture after coadministration of mannitol and ciclosporin.
Spontaneous allograft rupture after kidney transplantation is a rare complication usually due to an acute rejection of the interstitial type. In a 32-year-old man kidney transplantation was performed under immunosuppression with prednisolone and ciclosporin (CS). The dose of CS was 5 mg/kg body weight intravenously for the first 24 h, on the 2nd day 10 mg/kg/day orally, with gradually decreasing doses thereafter. The patient remained oliguric in the postoperative period and received additionally 600 ml mannitol solution intravenously for osmodiuresis within a period of 6 days. On the 8th postoperative day, 48 h after the last intravenous infusion of mannitol, spontaneous renal rupture occurred. The CS concentrations in the blood during the days before the rupture were within the upper normal range for effective immunosuppression (300-600 ng/ml). Intraoperatively the kidney appeared enlarged due to edematous swelling of the graft, but it showed no signs of rejection. The histological finding was a toxic tubulopathy with extensive isometric vacuolization and peritubular congestion, a known side effect of both of CS and of mannitol. The rupture was successfully repaired. Thirty-four days after the transplantation diuresis increased and hemodialysis therapy could be discontinued. In a second biopsy of the kidney the signs of toxic tubulopathy with isometric vacuolization were reduced. On the following days the serum creatinine dropped below 160 mumol/l. It can be assumed that the combination of CS therapy and administration of massive and continued doses of mannitol in an oliguric patient with allograft kidney may potentiate severe tubulopathy with concomitant edematous swelling of the graft. This can result in an increasing danger of spontaneous renal rupture.
Biesenbach
G
G
Second Department of Medicine (Section Nephrology), General Hospital Linz, Austria.
Zazgornik
J
J
Kaiser
W
W
Grafinger
P
P
Stuby
U
U
Gross
C
C
Hartl
P
P
Brücke
P
P
D000328:Adult; D001706:Biopsy; D003404:Creatinine / Q000097:blood; D016572:Cyclosporine / Q000008:administration & dosage / Q000009:adverse effects*; D006084:Graft Rejection / Q000517:prevention & control; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage / Q000009:adverse effects; D007275:Injections, Intravenous; D007668:Kidney / Q000473:pathology; D007674:Kidney Diseases / Q000097:blood / Q000139:chemically induced / Q000473:pathology; D016030:Kidney Transplantation; D007684:Kidney Tubules / Q000187:drug effects / Q000473:pathology*; D008297:Male; D008353:Mannitol / Q000008:administration & dosage / Q000009:adverse effects*; D012422:Rupture, Spontaneous; D014184:Transplantation, Homologous
D007166:Immunosuppressive Agents; D008353:Mannitol; D016572:Cyclosporine; D003404:Creatinine