2289 Clostridioides difficile-Associated Hemolytic Uremic Syndrome After Orthotopic Liver Transplantation

Abstract

INTRODUCTION: Clostridium Difficile infection (CDI) has previously been reported as a rare cause of possible Hemolytic Uremic Syndrome (HUS) in both adults and children. We present a unique case of CDI related HUS in a patient post orthotopic liver transplantation (OLT). CASE DESCRIPTION/METHODS: A 40-year-old African American male presented with acute decompensation of alcoholic cirrhosis. After evaluation, the patient underwent successful OLT. Post-transplant course was complicated by post-operative bleeding requiring multiple exploratory laparotomies. Patient developed new-onset acute renal failure post transplantation requiring hemodialysis and prolonged courses of antibiotics. On post op day 15, patient developed diarrhea and tested positive for CDI. Physical examination was significant for jaundice, multiple ecchymoses, and a large abdominal wound without signs of excessive erythema. Laboratory data at that time showed hemoglobin drop to 5 g/dL from 8.7 g/dL, thrombocytopenia with a drop in platelets from 282 × 103/uL to 15 × 103/uL, and blood smear consistent with presence of schistocytes raising the concern for a hemolytic process. Lactate dehydrogenase (LDH) was greater than 6450 U/L, haptoglobin was less than 6 mg/dL, and reticulocytes were elevated at 8.06%. ADAMSTS-13 resulted at 26% with a negative ADMASTS-13 antibody screen suggestive against thrombotic thrombocytopenic purpura. Serotonin release assay antibodies and heparin induced thrombocytopenia antibodies were not present. A diagnosis HUS secondary to CDI was made, and the patient was started on treatment for severe CDI with oral vancomycin, vancomycin enemas, and intravenous metronidazole. The patient also underwent emergent plasma exchange receiving 4 treatments, blood transfusions, and prednisone therapy (1 mg/kg). The patient had improvement in his hemoglobin and platelets following therapy and eventual resolution of diarrhea. His mental status as well returned to baseline. Patient’s hospital course was later complicated by aright hemicolectomy, end ileostomy secondary to toxic megacolon, and pathology was consistent with pseudomembranous colitis.His renal function did not recover and he was declared end-stage renal disease. DISCUSSION: CDI related HUS is exceedingly rare. The pathogenesis of CDI related HUS has not been well defined. To our knowledge, this is the first case of CDI related HUS in a patient post OLT. It is important for gastroenterologists and hepatologists to be aware that although rare, CDI is a possible cause of HUS.