Acute pancreatitis associated with everolimus after kidney transplantation: a case report

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Background:
Acute pancreatitis (AP) following KT is a rare and often fatal complication of the early post-transplant period. Common causative factors for AP are rare after KT; anti-rejection drugs as CyA, prednisone and MMF have been implicated, although evidence is not strong and we found no reports on possible causative role for mTOR inhibitors.

Case presentation:
A 55-year-old Caucasian man with end-stage renal disease due to idiopathic membrano-prolipherative glomerulonephritis underwent single kidney transplantation (KT) from cadaveric donor. Anti-rejection protocol was based on Basiliximab induction followed by prednisone and mycophenolate mophetil (MMF) and Cyclosporine; Everolimus (Eve) was scheduled to substitute MMF at week 3. At day 1 he had an asymptomatic elevation of pancreatic enzymes, spontaneously resolved. The further course was unremarkable and on day 19 he started Eve, with following asymptomatic rise in pancreatic enzymes. At day 33 the patient presented with abdominal pain and a marked elevation in serum amylase (1383 U/l) and lipase (1015 U/l), normal liver enzymes and bilirubin, no hypercalcemia, mild elevation in triglycerids; RT-PCRs for Cytomegalovirus or Epstein-Barr virus were negative. The patient had no history of alcohol abuse; ultrasound, CT and MRI found no evidence of biliary lithiasis. CT scans showed a patchy fluid collection in the pancreatic head area, consistent with idiopathic necrotizing pancreatitis. The patient was treated medically and Eve was withdrawn 1 week after. Patient underwent guided drainage of the fluid collection, but developed bacterial sepsis; surgical intervention was required with debridement of necrotic tissue, lavage and drainage; immunosuppression was totally withdrawn. Following course was complicated with multiple systemic infection. Transplantectomy for acute rejection was performed, and patient entered hemodialysis.

Conclusions:
Our patient had a presentation that is consistent for a causative role of Eve. A predisposing condition (acute pancreatic insult during transplant surgery) spontaneously resolved, relapsed and evolved rapidly in AP after the initiation of treatment with Eve with a consistent time latency. None of the well-known common causative factors for AP was present. We discourage the use of Eve in patients with recent episodes of sub-clinical pancreatitis, since it may represent a precipitating factor or interfere with resolution.

Keywords:
Everolimus, Acute pancreatitis, Kidney transplantation, Case report

Autoři: Francesco Fontana ^*; Gianni Cappelli
Působiště autorů: Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
Vyšlo v časopise: BMC Nefrol 2016, 17:163
Kategorie: Case report
prolekare.web.journal.doi_sk: https://doi.org/10.1186/s12882-016-0376-6

© 2016 The Author(s).

Open access
This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
The electronic version of this article is the complete one and can be found online at: http://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-016-0376-6

Souhrn

Keywords:
Everolimus, Acute pancreatitis, Kidney transplantation, Case report

Zdroje

1. Starzl TE. Experience in Renal Transplantation. Philadelphia: WB Saunders Co; 1994.

2. Slakey DP, Johnson CP, Cziperle DJ, Roza AM, Wittmann DH, Gray DW, et al. Management of severe pancreatitis in renal transplant recipients. Ann Surg. 1997;225:217–22.

3. Burnstein M, Salter D, Cardella C, Himal HS. Necrotizing pancreatitis in renal transplant patients. Can J Surg J Can Chir. 1982;25:547–9. 563.

4. Reischig T, Bouda M, Opatrny K, Tesinsky P, Cepelak M, Duras P, et al. Management of acute necrotizing pancreatitis after renal transplantation. Transplant Proc. 2001;33:2020–3.

5. Trivedi CD, Pitchumoni CS. Drug-induced pancreatitis: an update. J Clin Gastroenterol. 2005;39:709–16.

6. Badalov N, Baradarian R, Iswara K, Li J, Steinberg W, Tenner S. Drug-induced acute pancreatitis: an evidence-based review. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2007;5:648–61. quiz 644.

7. Vinklerová I, Procházka M, Procházka V, Urbánek K. Incidence, severity, and etiology of drug-induced acute pancreatitis. Dig Dis Sci. 2010;55: 2977–81.

8. Kasiske BL, K/DOQI Dyslipidemia Work Group. Clinical practice guidelines for managing dyslipidemias in kidney transplant patients. Am J Transplant Off J Am Soc Transplant Am Soc Transpl Surg. 2005;5:1576.

9. Lorber MI, Van Buren CT, Flechner SM, Williams C, Kahan BD. Hepatobiliary and pancreatic complications of cyclosporine therapy in 466 renal transplant recipients. Transplantation. 1987;43:35–40.

10. Subramaniam S, Zell JA, Kunz PL. Everolimus causing severe hypertriglyceridemia and acute pancreatitis. J Natl Compr Cancer Netw JNCCN. 2013;11:5–9.

11. Piao SG, Bae SK, Lim SW, Song J-H, Chung BH, Choi BS, et al. Drug interaction between cyclosporine and mTOR inhibitors in experimental model of chronic cyclosporine nephrotoxicity and pancreatic islet dysfunction. Transplantation. 2012;93:383–9.

12. Fernández-Cruz L, Targarona EM, Cugat E, Alcaraz A, Oppenheimer F. Acute pancreatitis after renal transplantation. Br J Surg. 1989;76:1132–5.

13. Baron TH, Morgan DE. Acute necrotizing pancreatitis. N Engl J Med. 1999; 340:1412–7.

14. Valdivielso P, Ramírez-Bueno A, Ewald N. Current knowledge of hypertriglyceridemic pancreatitis. Eur J Intern Med. 2014;25:689–94.