Case Reports in Transplantation

Case Report

Fatal Lactic Acidosis in a Kidney Transplant Recipient on Combination Antiretroviral Therapy after Initiation of Tacrolimus Therapy

Table 1

Haematology, biochemistry, thrombosis, and virology test results at various time points prior to and following renal transplantation.


Variable	Reference range (min, max), adults	Pretransplant	4–6 weeks prior to tacrolimus initiation	One week following tacrolimus initiation	Two weeks following tacrolimus initiation

Haematology
Haemoglobin (g/dL)	13.0, 17.0	11.8	12.5	12.5	12.9
White cell count	4.0, 11.0	9.0	8.8	12.6	10.9
Platelet count	150, 400	268	308	255	229
CD4 Lymphocytes (per μL)	300, 1400	1188	956	235	21

Coagulation
Activated partial thromboplastin time ratio	0.85, 1.16	0.91	1.08	1.23	1.51
International normalized ratio	0.90, 1.10	1.03	1.04	1.10	1.59

Clinical Chemistry
Sodium (mmol/L)	135, 145	133	136	134	130
Potassium (mmol/L)	3.5, 5.0	4.3	4.3	4.6	5.1
Bicarbonate (mmol/L)	22, 30	25	26	19	15
Urea (mmol/L)	1.7, 8.3	22.0	7.8	14.4	14.1
Creatinine (μmol/L)	59, 104	1415	156	206	233
Albumin (g/L)	40, 52	46	46	37	32
Alkaline phosphatase (IU/L)	35, 129	62	205	236	383
Bilirubin (μmol/L)	0, 16	7	6	10	44
Alanine transaminase (IU/L)	4, 59	36	20	65	141
Gamma-glutamyl transferase (IU/L)	4, 72	42	61	354	1500
Creatine kinase (IU/L)	0, 229	Not measured	Not measured	Not measured	1468
Lactic acid (mmol/L)	0.4, 2.2	Not measured	Not measured	Not measured	18

Virology
Hepatitis C RNA (IU/mL)		< 15	Not measured	Not measured	<15
HIV-1 RNA (copies/mL)		<40	<40	Not measured	<40
CMV DNA (copies/mL)		Not applicable	Not detected	Not detected	Not detected

Drug levels
Ciclosporin level (μg/L)	100, 200	Not applicable	74	Not applicable	Not applicable
Tacrolimus level (μg/L)	8, 12	Not applicable	Not applicable	26	13

Antiviral medications		6 weeks prior to transplantation	15 weeks following transplant: on ciclosporin	NR	2 weeks after switching to tacrolimus
Abacavir (mean steady state ^§C_min, C_max; ng/mL)	10, 3000	1551	1611	NR	538
Lamivudine (mean steady state ^†C_min, C_max; ng/mL)	90, 1200	794	1615	NR	717
Nevirapine (therapeutic range min, max; ng/mL)	3000, 8000^‡	5227	Not measured	NR	5488

Estimated from therapeutic doses of ^§300 mg abacavir twice daily and ^†150 mg lamivudine twice daily (values derived from Delphic Laboratories (Liverpool) ltd.).