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to deferasirox, this recent evidence demonstrates that careful monitoring of renal function and ferritinaemia in patients receiving deferasirox is mandatory. This case illustrates the importance for nephrologists, haematologists and internists to be aware of potentially severe renal complications of this recently commercialized drug, in order to prevent progressive kidney disease. Conflict of interest statement. None declared.
References
4. Brosnahan G, Gokden N, Swaminathan S. Acute interstitial nephritis due to deferasirox: a case report. Nephrol Dial Transplant 2008; 23: 3356–3358 5. Yusuf B, McPhedran P, Brewster UC. Hypocalcemia in a dialysis patient treated with deferasirox for iron overload. Am J Kidney Dis 2008; 52: 587–590 6. Rafat C, Fakhouri F, Ribeil JA et al. Fanconi syndrome due to deferasirox. Am J Kidney Dis 2009; 54: 931–934 7. Even-Or E, Becker-Cohen R, Miskin H. Deferasirox treatment may be associated with reversible renal Fanconi syndrome. Am J Hematol 2010; 85: 132–134 8. Gattermann N, Zoumbos N, Angelucci E et al. Impact on iron removal of dose reduction for non-progressive serum creatinine increases during treatment with the once-daily, oral iron. chelator deferasirox (Exjade, ICL670). Blood 2006; 108: 3824 abstract 9. Papassotiriou I, Margeli A, Hantzi E et al. Cystatin C levels in patients with beta-thalassemia during deferasirox treatment. Blood Cells Mol Dis 2010; 44: 152–155 10. Vanorden HE, Hagemann TM. Deferasirox—an oral agent for chronic iron overload. Ann Pharmacother 2006; 40: 1110–1117 11. Hider RC. Charge states of deferasirox–ferric iron complexes. Am J Kidney Dis 2010; 55: 614–615 Received for publication: 21.3.10; Accepted in revised form: 31.3.10
Nephrol Dial Transplant (2010) 25: 2378–2380 doi: 10.1093/ndt/gfq228 Advance Access publication 2 May 2010
Successful management of recurrent pregnancy-related thrombotic thrombocytopaenia purpura in a renal transplant recipient Kimberly Lam1, Vanessa Martlew2, Steve Walkinshaw3, Zarko Alfirevic4 and Matthew Howse1 1
Department of Nephrology, Royal Liverpool and Broadgreen University Hospital, NHS Trust, Liverpool, UK, 2Departrment of Haematology, Royal Liverpool and Broadgreen Unversital, Hospital, NHS Trust, Liverpool, UK, 3Department of Obstetrics, Liverpool Women’s Hospital NHS Trust, Liverpool, UK and 4Department of Reproductive and Developmental Medicine, University of Liverpool, Liverpool, UK Correspondence and offprint requests to: Matthew Howse; E-mail:
[email protected]
Abstract Thrombotic thrombocytopaenic purpura (TTP) is a rare but potentially devastating complication of pregnancy. We report the first documented case of a successful treatment of recurrent TTP complicating pregnancy in a renal transplant patient. Keywords: ADAMTS-13; pregnancy; renal transplant; thrombotic thrombocytopaenic purpura
In 2003, a 31-year-old nulliparous patient, with end-stage kidney disease secondary to chronic pyelonephritis, received a living-related transplant from her sister; immunosuppression was tacrolimus and mycophenolate mofetil (MMF). Graft function was excellent with a serum creati-
nine between 100 and 120 µmol/L. She subsequently requested preconception counselling. This included converting MMF to azathioprine 125 mg. She soon became pregnant. At the 22nd week of gestation, she presented with new-onset hypertension and proteinuria. There was also an absence of fetal movements. Investigations showed haemolytic anaemia (Hb 7.7 g/dL, LDH 1047 U/L) and thrombocytopaenia (47 × 109/mL). Microangiopathic haemolytic anaemia (MAHA) was confirmed on the blood film. Liver enzymes were normal, but there was renal graft dysfunction (creatinine 145 µmol/L). The diagnoses of thrombotic thrombocytopaenic purpura (TTP) and pre-eclampsia were made. Plasma exchange (PEX) was commenced using solvent–detergent virally inactivated fresh-frozen plasma (Octaplas) as replacement fluid. Tacro-
© The Author 2010. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please e-mail:
[email protected]
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1. Lindsey WT, Olin BR. Deferasirox for transfusion-related iron overload: a clinical review. Clin Ther 2007; 29: 2154–2166 2. Taher A, El-Beshlawy A, Elalfy MS et al. Efficacy and safety of deferasirox, an oral iron chelator, in heavily iron-overloaded patients with beta-thalassaemia: the ESCALATOR study. Eur J Haematol 2009; 82: 458–465 3. Cappellini MD, Porter J, El-Beshlawy A et al. Tailoring iron chelation by iron intake and serum ferritin: the prospective EPIC study of deferasirox in 1744 patients with transfusion-dependent anemias. Haematologica 2010; 95: 557–566
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limus was withdrawn to prevent TTP progression, and prednisolone 20 mg substituted. Subsequent scanning confirmed fetal death, and the pregnancy was terminated. The patient was very keen for a further pregnancy. She continued to take prednisolone 5 mg and azathioprine 125 mg as tacrolimus may have contributed to the development of TTP. Five months post-termination, she suffered an acute rejection of the renal allograft treated, with good response, with methylprednisolone. Subsequently, tacrolimus was re-introduced to prevent a further rejection. In May 2007, a second pregnancy was confirmed. The patient was monitored weekly from the 12th week of gestation including her ADAMTS-13 levels (Figure 1). We extrapolated experience from pregnancy in patients without transplants and planned to use a threshold of
