Acute Renal Failure Caused from Hyper-Uremic Acidemia in ABO Incompatible Kidney Transplant Maintained with Cyclosporine and High-Dose Mizoribine

Abstract

Introduction: From the shortage of cadaver donor, to expand living donor kidney transplant, number of ABO incompatible kidney transplant is increasing up to 30% or more in Japan. Marginally appropriate donors might be considered in order to extend the donor criteria. Here we report an outcome after ABO incompatible kidney transplant from an aged living-related donor with mild diabetes and hypertension. Case report: A 48 year-old male had ABO incompatible kidney transplant from his 76 years old father, and induced with anti-CD20 Antibody, cyclosporine (CsA), mycophenolate mofetil (MMF) and prednisolone (PSL). After the operation, MMF was switched to highdose mizoribine(MZ). He discharged from our hospital on 28POD, and serum Cr was 1.47mg/dl. On 34POD, sCr was 8.14mg/dl and he was re-hospitalized for graft biopsy. Urine examination showed uric acid crystal, and serum uric acid was 24.6mg/dl. Pathological findings showed no evidence of acute rejection but mild tubullo-interstitial injury. Hemodialysis was performed for twice to reduce uric acid, diurination was maintained good status with hydration. CsA and MZ ware switched to Tacrolims and MMF. Benzbromarone was switched to Febuxostat for treatment of hyper-uric acidemia. On POD58, sCr was reduced to 1.75mg/dl and he discharged our hospital. On POD 135, graft function was stable and sCr was 1.51mg/dl. Discussion and conclusion: It is reported that high-dose mizoribine is effective for maintenance of immunosuppression for ABO compatible and different kidney transplant. We used high-dose MZ regimen of ABO incompatible kidney transplant for 3 cases. In this case, the donor was marginally appropriate donor with mild diabetes and hypertension. One of common side effect of MZ is hyper-uric acidemia. Renal hypo-function itself might also affect hyper-uric acidemia. He suffered from acute renal failure suspiciously induced MZ, therefore immunosuppressant regimen should be carefully considered in aged marginal donor. However, it was effective enough to achieve appropriate result with marginal aged donor, however long-term careful observation for both the donor and recipient was required. Marginally appropriate donors could be considered in order to extend the donor criteria.