Mycophenolate mofetil in cyclosporin-associated thrombotic microangiopathy.

Abstract

They all had thrombocytopenia and schizocytes with Thrombotic microangiopathy is a syndrome in which other signs indicative of haemolysis. Moreover, the thrombocytopenia and microangiopathic haemolytic stability of SCr argue against vascular rejection. We anaemia occur together with acute renal failure and a attributed the thrombotic microangiopathy to CsA characteristic renal vascular pathology [1]. Its prevalbecause no patient had a past history of pre-transplant ence in renal transplant recipients is estimated to be thrombotic microangiopathy, allograft biopsies did not 4% [2]. Both experimental and clinical data suggest a demonstrate any signs of acute rejection and all the direct role for cyclosporin A (CsA) in the pathogenesis patients improved without rejection therapy after CsA of post-transplant thrombotic microangiopathy. Renal withdrawal. No infection previously associated with endothelial cell injury mediated through the inhibition thrombotic microangiopathy could be detected in any of PGI2 is believed to be the pathogenetic mechanism of the patients. of CsA-induced thrombotic microangiopathy [3,4]. In these cases, we decided to avoid the use of both Despite different therapeutic strategies, the prognosis CsA and Tacrolimus and to replace AZA by MMF. of CsA-associated thrombotic microangiopathy Large studies have demonstrated that MMF is superior remains poor. CsA withdrawal is the cornerstone of to AZA as a post-transplant immunosuppressant [8]. treatment. However, CsA withdrawal exposes the MMF may have a CsA-sparring effect allowing CsA patient to a major risk of acute rejection. Although withdrawal without acute rejection in post-transplant some authors have suggested that CsA reintroduction thrombotic microangiopathy. None of the three is possible, this attitude remains controversial because patients have experienced acute rejection 8, 11 and 17 of the possible relapse of a life-threatening disease [5]. months after transplantation, respectively. Although Some authors have reported successful conversion not controlled, this report suggests that an immunofrom CsA to Tacrolimus [6 ] but Tacrolimus has also suppressive regimen with steroids and MMF could be been associated with thrombotic microangiopathy [7]. effective when both CsA and Tacrolimus are contraWe describe a favourable course of CsA-associated indicated. Interestingly, Van Gelder et al. recently thrombotic microangiopathy in three renal transplant described a similar case report [9]. Because CsArecipients after CsA withdrawal and concomittant induced thrombotic microangiopathy is a rare condiswitch from azathioprine (AZA) to mycophenolate tion, individual anecdotes are the only information we mofetil (MMF ). have on managing this problem.