Tacrolimus-Induced Type IV Renal Tubular Acidosis following Liver Transplantation

Variables Associated With Hyperkalemic Renal Tubular Acidosis in Solid Organ Transplant Recipients

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.

Calcineurin Inhibitor-Induced Type IV Renal Tubular Acidosis in Post-Bone Marrow Transplant: Review of Pathophysiology and Principles of Management

Calcineurin inhibitors (CNI) are the mainstay of immunosuppressant medications in both bone marrow transplants and solid organ transplants. Nephrotoxicity is a well-known adverse effect of this group. Type IV renal tubular acidosis is a potentially under-recognized complication. Here we report a case of Omenn syndrome in a patient who underwent a bone marrow transplant and developed type IV renal tubular acidosis while on treatment with cyclosporine.