41 yo women 30 weeks pregnant (IVF twins) admitted to labor and delivery for possible preterm labor. She has a history of liver transplant 20 years ago for "autoimmune hepatitis" managed with tacrolimus; levels throughout pregnancy have been 3-5. She has had a mild transaminitis for the last several months (AST/ALT in the 125-200 range), mild hyperbilirubinemia (TB 2.5), mild hypoalbuminemia (alb 3.0), and normal INR. She has had chronic intermittent nausea/vomiting throughout pregnancy. In addition to prograf, her outpatient medication regimen includes lasix 40mg daily, which she has been on for "years" and has been continued during pregnancy.
On evaluation in labor and delivery, she is normotensive (105/75), with 1+ bilateral lower extremity edema. Over the next 36 hours, her renal function progressively declines: Cr 1.0 on admission, up to 1.3 then - despite 100ml/h normal saline for 8 hours - 1.6 mg/dl. No new meds, no contrast exposure, no NSAIDs. Prograf level 5 days ago was 5.0, and dosage was increased from 1.5mg bid to 2 mg bid. Repeat prograf level is pending. Ob/gyn says she is not in labor, and the fetuses are appropriate for gestational age.
Any ideas?
Interesting Case.
ReplyDeleteI would check her baseline creatinine. Creat 1.0 is abnormal. I would assume that she has underlying chronic CNI toxicity since she has been on CNI since longtime. Acute CNI is possible in the setting of recently increased dose of tacrolimus. Atypical presentation of preeclampsia is possible but unlikely. Renal ultrasound to r/o hydro and checking urinalysis/proteinuria/hematuria/platelet count would be helpful. I would cut back with the tacro dose particularly if she has stable transaminitis. temporal relation of transaminitis with pregnancy may be helpful to find out the etiology of liver dysfunction. Any rejection issues suspected to keep her levels high?. Any other meds contributing? urine electrolytes may give a clue for volume status etc. hepatorenal and cardiorenal unlikely.
How did you manage?