Acute Esophageal Necrosis Following Kidney Transplantation

Abstract

Acute esophageal necrosis (Black esophagus) is a rare complication typically seen as a circumferential black appearing esophagus in the less vascularized distal region. Etiologies include hypoperfusion, infectious etiologies (e.g. CMV, Candida albicans), DKA, and toxic ingestion. Two cases have been previously reported in kidney transplant recipients involving intra-operative cardiac arrest with associated hypotension, and primary CMV infection, respectively. Our patient developed acute esophageal necrosis without an episode of hypotension, or infectious etiology. A 48 year-old Asian man with end-stage renal disease due to IgA nephropathy received a deceased donor kidney transplant. Both donor and recipient had positive cytomegalovirus (CMV) IgG antibodies prior to transplant. The patient did not experience intraoperative hypotension. He received standard induction and maintenance immunotherapy including tacrolimus target trough levels between 8 and 10 ng/ml. Post-operatively, the patient developed hiccups, postprandial chest and epigastric pain, dysphagia, and odynophagia. He was afebrile, normotensive, and had no fever or evidence of gastrointestinal bleeding. Labs revealed a stable normocytic normochromic anemia with hemoglobin of 9.8g/dL without evidence of leukocytosis, thrombocytopenia and a normal coagulation profile. At symptom onset, tacrolimus level was slightly elevated at 11.1 ng/ml, and his serum creatinine peaked at 15.4. Hemodialysis was started without symptomatic improvement. On POD 4, patient underwent esophagogastroduodenoscopy (EGD) that demonstrated evidence of diffuse blackdiscoloration, ulceration and erythema in the distal esophagus. Biopsies were consistent with necrosis and showed no evidence of CMV infection. Conservative management including NPO, TPN, and PPI for one week led to marked improvement in symptoms and EGD two weeks later revealed adequate reepithelization and no visualization of necrotic tissue (Figure 1D-F). Despite the absence of frank hypotension, infections or DKA, acute esophageal necrosis may occur in the setting of normal blood pressure and major surgery. It is difficult to determine, but tacrolimus with vasoconstrictive properties could have resulted in distal esophageal hypoperfusion and subsequent necrosis. The current case raises clinician awareness in considering the possibility of esophageal necrosis post-transplant in the setting of dysphagia, odynophagia, and elevated tacrolimus levels.1827 Figure 1. A) Normal-appearing upper esophagus on initial EGD. B) Middle esophageal tissue discoloration, erythema and friability with contact bleeding. C) Lower esophageal tissue friability, ulceration and sloughing. D) Normal-appearing upper esophagus on follow-up EGD one week afterwards. E) Normal-appearing middle esophagus. F) Erythema and evidence of re-epithelization in lower third of the esophagus.