1
|
Mohib O, Vanderhulst J, Catalano C, Roussoulières A, Knoop C, Lemoine A, Baudoux T. Variables Associated With Hyperkalemic Renal Tubular Acidosis in Solid Organ Transplant Recipients. Cureus 2024; 16:e55379. [PMID: 38434606 PMCID: PMC10908377 DOI: 10.7759/cureus.55379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2024] [Indexed: 03/05/2024] Open
Abstract
INTRODUCTION The occurrence of hyperkalemic renal tubular acidosis (RTA) in the post-transplantation period is likely underestimated, and its identification remains important to offer adequate medical management. Transplant recipients frequently present with clinical and biological characteristics that may be associated with the occurrence of this complication. METHODS This was a single-center retrospective study that compared transplanted patients with hyperkalemic RTA and a control group to identify variables associated with the occurrence of this complication. Fisher's exact test and the Mann-Whitney test, followed by multivariate logistic regression, were applied to test whether there was a significant association between hyperkalemic RTA and different variables. RESULTS Kidney and heart transplant recipients were at greater risk of developing RTA than lung transplant recipients (p = 0.016). There was also a significant association between the development of RTA and kalemia (p < 0.01), chloremia (p < 0.01), and bicarbonatemia (p < 0.01). The significant impact of these last three variables was confirmed by the results of the multivariate logistic regression. Residual serum tacrolimus levels (p = 0.13) and creatinine levels (p = 0.17) of renal transplant patients were not significantly associated with hyperkalemic RTA. CONCLUSION The type of transplanted organ, kalemia, chloremia, and bicarbonatemia were significantly associated with the occurrence of hyperkalemic RTA. This study calls into question certain approaches to managing this complication proposed in a number of case reports, such as reducing the target serum residual of tacrolimus or discontinuing trimethoprim-sulfamethoxazole (TMP-SMX) in favor of another antibiotic prophylactic agent, potentially exposing patients to graft rejection and opportunistic infections.
Collapse
Affiliation(s)
- Othmane Mohib
- Department of Nephrology, Cliniques Universitaires de Bruxelles - Hôpital (CUB) Erasme, Brussels, BEL
| | - Julien Vanderhulst
- Internal Medicine, Centre Hospitalier Universitaire (CHU) Brugmann, Brussels, BEL
| | - Concetta Catalano
- Department of Nephrology, Cliniques Universitaires de Bruxelles - Hôpital (CUB) Erasme, Brussels, BEL
| | - Ana Roussoulières
- Department of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital (CUB) Erasme, Brussels, BEL
| | - Christiane Knoop
- Department of Pulmonology, Cliniques Universitaires de Bruxelles - Hôpital (CUB) Erasme, Brussels, BEL
| | - Alain Lemoine
- Department of Nephrology, Cliniques Universitaires de Bruxelles - Hôpital (CUB) Erasme, Brussels, BEL
| | - Thomas Baudoux
- Department of Nephrology, Cliniques Universitaires de Bruxelles - Hôpital (CUB) Erasme, Brussels, BEL
| |
Collapse
|
2
|
Gheith OA, Dahab M, Nagib AM, Adel M, Elserwy N, Sobhy I, AbdelMonem M, Abo Atya H, Al-Otaibi T. Fludrocortisone Among Adult Renal Transplant Recipients With Persistent Hyperkalemia: Single-Center Experience. EXP CLIN TRANSPLANT 2022; 20:69-73. [PMID: 35384810 DOI: 10.6002/ect.mesot2021.o27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Calcineurin inhibitors are the cornerstone of immunosuppression following solid-organ transplant. However, hyperkalemia may occur by multiple mechanisms affecting potassium in the distal tubule. Hyperkalemia is commonly observed in renal transplant recipients, and it is dose-dependent. Here, we evaluated the impact of fludrocortisone in the management of calcineurin inhibitor-induced hyperkalemia after renal transplant. MATERIALS AND METHODS We evaluated newly transplanted patients who developed hyperkalemia or those with hyperkalemia who attended our outpatient renal transplant clinic (Hamed Al-Essa Organ Transplant Center, Kuwait). Clinical and laboratory parameters were collected before starting fludrocortisone (baseline values) and then at 1, 2, 4, and 8 weeks. Drug history was assessed, with any drugs that could induce hyperkalemia being discontinued (such as spironolactone); otherwise, essential drugs like prophylactic agents (sulfamethoxazole-trimethoprim) were maintained. Oral anti-hyperkalemic doses (bicarbonate, resonium calcium, fludrocortisone) were noted. RESULTS Our study included 29 patients; most were men (aged 45.8 ± 15 years). Body weight did not significantly change after introduction of fludrocortisone (79.53 ± 24.31, 79.82 ± 23.85, 80.62 ± 24.24, 77.03 ± 20.7, and 79.21 ± 27.93 kg at baseline and at postdose week 1, 2, 4, and 8, respectively). Systolic and diastolic blood pressure levels were also similar at baseline versus postdose. Steroid doses (prednisolone) were significantly reduced over 1 month (15.7 ± 12.4, 14.1 ± 10.19, 12.6 ± 8.7, 9.5 ± 5.2, and 9.5 ± 5.2 mg/ day). Serum potassium levels significantly improved (5.18 ± 0.58, 4.9 ± 0.49, 4.8 ± 0.54, 4.8 ± 0.65, and 4.4 ± 0.72 mmol/L). Serum creatinine levels significantly improved by postdose week 8 (129.28 ± 48.9, 130.92 ± 52.2, 127.66 ± 50.9, 121.42 ± 41.7, and 124.1 ± 51.27 μmol/L). Serum bicarbonate levels remained similar. CONCLUSIONS Fludrocortisone was a safe and effective option in management of calcineurin inhibitor-induced hyperkalemia among renal transplant recipients.
Collapse
Affiliation(s)
- Osama A Gheith
- From the Nephrology Department, Hamed Al-Essa Organ Transplant Center, Sabah Area, Kuwait.,From the Nephrology and Transplantation Unit, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Gama RM, Makanjuola D, Wahba M, Quan V, Phanish M. Fludrocortisone Is an Effective Treatment for Hyperkalaemic Metabolic Acidosis in Kidney Transplant Recipients on Tacrolimus: A Case Series. Nephron Clin Pract 2021; 146:190-196. [PMID: 34784594 DOI: 10.1159/000519670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/13/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hyperkalaemia with metabolic acidosis is common but under-reported following kidney transplantation. Calcineurin inhibitors, such as tacrolimus, are widely used in the management of transplant patients and are associated with the development of hyperkalaemia. We report on 10 renal transplant patients, treated with fludrocortisone, following identification of hyperkalaemic metabolic acidosis. RESULTS All 10 patients were male aged (mean ± SD) 53.0 ± 13.2 years; 7 were Caucasian and 3 South Asian. Before and after fludrocortisone administration, respective (mean ± SD) serum potassium was 6.1 ± 0.4 mmol/L and 5.3 ± 0.3 mmol/L (p = 0.0002); serum bicarbonate 18.5 ± 1.6 mmol/L and 20.5 ± 2.3 mmol/L (p = 0.002); serum sodium 135 ± 4.6 mmol/L and 137 ± 2.2 mmol/L (p = 0.0728); serum creatinine 181 ± 61 μmol/L and 168 ± 64 μmol/L (p = 0.1318); eGFR 42 ± 18 mL/min and 46 ± 18 mL/min (p = 0.0303); blood tacrolimus 10.1 ± 2.9 ng/mL and 10.4 ± 1.4 ng/mL (p = 0.7975); and blood pressure 129 ± 15/79 ± 25 mm Hg and 126 ± 24/75 ± 7 mm Hg. Pre-fludrocortisone, there were 7 episodes of serum potassium ≥6.5 mEq/L, with 4 patients requiring admission for the treatment of hyperkalaemia. Following fludrocortisone, no patients had hyperkalaemia requiring inpatient management. CONCLUSIONS Treatment of hyperkalaemic metabolic acidosis in transplant patients on tacrolimus with low-dose fludrocortisone resulted in rapid correction of hyperkalaemia and acidosis without significant effects on blood pressure or serum sodium. Fludrocortisone can be an effective short-term option for the treatment of hyperkalaemic metabolic acidosis in kidney transplant recipients on tacrolimus; however, patient selection remains important in order to reduce to risk of potential adverse effects.
Collapse
Affiliation(s)
- Rouvick M Gama
- Renal Unit, St. Helier Hospital, Epsom and St Helier University Hospitals NHS Trust, Carshalton, United Kingdom
| | - David Makanjuola
- Renal Unit, St. Helier Hospital, Epsom and St Helier University Hospitals NHS Trust, Carshalton, United Kingdom
| | - Mona Wahba
- Renal Unit, St. Helier Hospital, Epsom and St Helier University Hospitals NHS Trust, Carshalton, United Kingdom
| | - Virginia Quan
- Renal Unit, St. Helier Hospital, Epsom and St Helier University Hospitals NHS Trust, Carshalton, United Kingdom
| | - Mysore Phanish
- Renal Unit, St. Helier Hospital, Epsom and St Helier University Hospitals NHS Trust, Carshalton, United Kingdom
| |
Collapse
|
4
|
Palmer BF, Kelepouris E, Clegg DJ. Renal Tubular Acidosis and Management Strategies: A Narrative Review. Adv Ther 2021; 38:949-968. [PMID: 33367987 PMCID: PMC7889554 DOI: 10.1007/s12325-020-01587-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/26/2020] [Indexed: 12/29/2022]
Abstract
Renal tubular acidosis (RTA) occurs when the kidneys are unable to maintain normal acid−base homeostasis because of tubular defects in acid excretion or bicarbonate ion reabsorption. Using illustrative clinical cases, this review describes the main types of RTA observed in clinical practice and provides an overview of their diagnosis and treatment. The three major forms of RTA are distal RTA (type 1; characterized by impaired acid excretion), proximal RTA (type 2; caused by defects in reabsorption of filtered bicarbonate), and hyperkalemic RTA (type 4; caused by abnormal excretion of acid and potassium in the collecting duct). Type 3 RTA is a rare form of the disease with features of both distal and proximal RTA. Accurate diagnosis of RTA plays an important role in optimal patient management. The diagnosis of distal versus proximal RTA involves assessment of urinary acid and bicarbonate secretion, while in hyperkalemic RTA, selective aldosterone deficiency or resistance to its effects is confirmed after exclusion of other causes of hyperkalemia. Treatment options include alkali therapy in patients with distal or proximal RTA and lowering of serum potassium concentrations through dietary modification and potential new pharmacotherapies in patients with hyperkalemic RTA including newer potassium binders.
Collapse
|
5
|
Farouk SS, Rein JL. The Many Faces of Calcineurin Inhibitor Toxicity-What the FK? Adv Chronic Kidney Dis 2020; 27:56-66. [PMID: 32147003 DOI: 10.1053/j.ackd.2019.08.006] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 08/01/2019] [Indexed: 02/07/2023]
Abstract
Calcineurin inhibitors (CNIs) are both the savior and Achilles' heel of kidney transplantation. Although CNIs have significantly reduced rates of acute rejection, their numerous toxicities can plague kidney transplant recipients. By 10 years, virtually all allografts will have evidence of CNI nephrotoxicity. CNIs have been strongly associated with hypertension, dyslipidemia, and new onset of diabetes after transplantation-significantly contributing to cardiovascular risk in the kidney transplant recipient. Multiple electrolyte derangements including hyperkalemia, hypomagnesemia, hypercalciuria, metabolic acidosis, and hyperuricemia may be challenging to manage for the clinician. Finally, CNI-associated tremor, gingival hyperplasia, and defects in hair growth can have a significant impact on the transplant recipient's quality of life. In this review, the authors briefly discuss the pharmacokinetics of CNI and discuss the numerous clinically relevant toxicities of commonly used CNIs, cyclosporine and tacrolimus.
Collapse
|
6
|
Avila-Poletti D, De Azevedo L, Iommi C, Heldal K, Musso CG. Hyperchloremic metabolic acidosis in the kidney transplant patient. Postgrad Med 2019; 131:171-175. [PMID: 30924703 DOI: 10.1080/00325481.2019.1592360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Hyperchloremic metabolic acidosis of renal origin results from a defect in renal tubular acidification mechanism, and this tubular dysfunction can consist of an altered tubular proton secretion or bicarbonate reabsorption capability. Studies have documented that all forms of renal tubular acidosis (RTA), type I to IV, are documented in kidney transplant patients. Among RTA pathophysiologic mechanisms have been described the renal mass reduction, hyperkalemia, hyperparathyroidism, graft rejection, immunologic diseases, and some drugs such as renin-angiotensin-aldosterone blockers, and calcineurin inhibitors. RTA can lead to serious complications as is the case of muscle protein catabolism, muscle protein synthesis inhibition, renal osteodystrophy, renal damage progression, and anemia promotion. RTA should be treated by suppressing its etiologic factor (if it is possible), avoiding hyperkalemia, and/or supplying bicarbonate or a precursor (citrate). In conclusion: Hyperchloremic metabolic acidosis of renal origin is a relatively frequent complication in kidney transplantation patients, which can be harmful, and should be adequately treated in order to avoid its renal and systemic adverse effects.
Collapse
Affiliation(s)
- Debora Avila-Poletti
- a Human Physiology Department , Instituto Universitario del Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Leticia De Azevedo
- a Human Physiology Department , Instituto Universitario del Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Candela Iommi
- a Human Physiology Department , Instituto Universitario del Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Kristian Heldal
- b Clinic of Internal Medicine, Telemark Hospital Trust , Skien , Norway.,c Institute of Clinical Medicine, Faculty of Medicine of University of Oslo , Oslo , Norway
| | - Carlos G Musso
- a Human Physiology Department , Instituto Universitario del Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| |
Collapse
|
7
|
Ali SR, Shaheen I, Young D, Ramage I, Maxwell H, Hughes DA, Athavale D, Shaikh MG. Fludrocortisone-a treatment for tubulopathy post-paediatric renal transplantation: A national paediatric nephrology unit experience. Pediatr Transplant 2018; 22. [PMID: 29345400 DOI: 10.1111/petr.13134] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2017] [Indexed: 11/30/2022]
Abstract
Calcineurin inhibitors post-renal transplantation are recognized to cause tubulopathies in the form of hyponatremia, hyperkalemia, and acidosis. Sodium supplementation may be required, increasing medication burden and potentially resulting in poor compliance. Fludrocortisone has been beneficial in addressing tubulopathies in adult studies, with limited paediatric data available. A retrospective review of data from an electronic renal database from December 2014 to January 2016 was carried out. Forty-seven post-transplant patients were reviewed with 23 (49%) patients on sodium chloride or bicarbonate. Nine patients, aged 8.3 years (range 4.9-16.4), commenced fludrocortisone 22 months (range 1-80) after transplant and were followed up for 9 months (range 2-20). All patients stopped sodium bicarbonate; all had a reduction or no increase in total daily doses of sodium chloride. Potassium levels were significantly lower on fludrocortisone, 5.2 vs 4.5 mmol/L, P = .04. No difference was noted in renal function (eGFR 77.8 vs 81.7 mL/min/1.73 m2 , P = .45) and no significant increase in systolic blood pressure (z-scores 0.99 vs 0.85, P = .92). No side effects secondary to treatment with fludrocortisone were reported. A significant proportion of renal transplant patients were on sodium supplementation and fludrocortisone reduced sodium supplementation without significant effects on renal function or blood pressure. Fludrocortisone appears to be safe and effective for tubulopathies in children post-transplantation.
Collapse
Affiliation(s)
- S R Ali
- Department of Paediatric Nephrology, Royal Hospital for Children, Glasgow, UK
| | - I Shaheen
- Department of Paediatric Nephrology, Royal Hospital for Children, Glasgow, UK
| | - D Young
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | - I Ramage
- Department of Paediatric Nephrology, Royal Hospital for Children, Glasgow, UK
| | - H Maxwell
- Department of Paediatric Nephrology, Royal Hospital for Children, Glasgow, UK
| | - D A Hughes
- Department of Paediatric Nephrology, Royal Hospital for Children, Glasgow, UK
| | - D Athavale
- Department of Paediatric Nephrology, Royal Hospital for Children, Glasgow, UK
| | - M G Shaikh
- Department of Paediatric Endocrinology and Diabetes, Royal Hospital for Children, Glasgow, UK
| |
Collapse
|
8
|
Tacrolimus-Induced Type IV Renal Tubular Acidosis following Liver Transplantation. Case Reports Hepatol 2017; 2017:9312481. [PMID: 28761769 PMCID: PMC5518501 DOI: 10.1155/2017/9312481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 06/01/2017] [Indexed: 11/17/2022] Open
Abstract
Calcineurin inhibitors remain an integral component of immunosuppressive therapy regimens following solid organ transplantation. Although nephrotoxicity associated with these agents is well documented, type IV renal tubular acidosis is a rare and potentially underreported complication following liver transplantation. Hepatologists must be able to recognize this adverse effect as it can lead to fatal hyperkalemia. We describe a case of tacrolimus-induced hyperkalemic type IV renal tubular acidosis in a patient following an orthotopic liver transplant for alcoholic cirrhosis.
Collapse
|