강병모

475

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A case of vildagliptin induced-Hepatotoxicity in patient after ABOi renal transplantation.

1메리놀 병원 내과, ²메리놀 병원 신장내과, ³ 메리놀 병원 내분비 내과

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강병모

, 이희룡

, 이동렬

, 박수경

, 안정명

During early period, ABO-incompatible(ABOi) renal transplanted patients need a variety of drug associated with immunusuppresion, prophylaxis of op- portunistic infections and treatment of underline diseases. It is important to understand side effects of each drug. Dipeptidyl peptidase-4(DPP-4) inhibitors are a class of oral diabetes drugs, which block the degradation of incretin, enhance incretin levels, stimulate insulin secretion and decrease glucagon production. DPP-4 inhibitors are considered a favorable safe drug and have used widely. However recently there are several case-reports of liver injury as- sociated with DPP4-inhibitors. We present a case of vildagliptin-induced hepatotoxicty during early period after ABOi-renal transplantation. A 44-year-old man with end stage renal disease due to diabetic nephropathy received ABOi-kidney transplantation from wife. The patient’s blood group was A positive, whereas his wife was B positive. The baseline IgG anti-B isoagglutinin titer was 1:32 and the number of HLA mismatch was one(A0, B1, DR0). Using low-dose rituximab, plasmapheresis, and IVIG, he had been successfully done ABOi renal transplantation. At the time of discharge, he was prescribed ta- crolimus, mycophenolate mofetil, deflazacort, trimethoprim/sulfamethoxazole(TMP/SMX), valaciclovir, amlodipine, atenolol, doxazosin, aspirin, ferrous sulfate and ranitidine. As his glucose level increased, metformin and vildagliptin were added. On postoperative day 35, his liver enzymes were elevated. We immediately decided to hold TMP/SMX and valaciclovir. During one month, his liver enzymes were not changed. We switched his drug one by one.

Lowering his blood pressure, we discontinued amlodipine and doxazosin. Also we changed anti-diabetic drug. After we switched vildagliptin with glime- piride, his liver enzymes were normalized. After administration of DPP4 inhibitor, it may be necessary to monitor live function in renal transplanted patients.

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Formation of Renal Abscess in a Patient with Non-Small Cell Lung cancer treated with Crizotinib

충남대학교병원 신장내과

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이유진, 김해리, 전재완, 함영록, 최대은, 이강욱, 나기량

Crizotinib is a selective inhibitor of ALK, c-MET and ROS1. Previous clinical trials reported complex renal cysts as a rare complication of crizotinib with an incidence of 1％ up to 22％, more recently. We report a case of renal abscess formation in a patient with NSCLC treated with crizotinib for 11 months. A 62-year-old woman presented with fever (40.1℃), chill and myalgia. She was diagnosed NSCLC (adenocarcinoma) 4 years ago and underwent right lower lobe lobectomy with mediastinal lymph node dissection and adjuvant chemotherapy (navelbine + cisplatin). She had no underlying renal disease or cystic kidney disease. Malignant pleural effusion (right) and ALK rearrangement (55％) was found. She had been on crizotinib for 11 months before hospital- ization to our divison. The initial laboratory results showed mild leukocytosis (WBC 11,800/㎕), slightly elevated C-reactive protein (2.0mg/㎗) and pyuria.

Abdominopelvic CT scan revealed a 3.5cm amorphic multilobulated rim enhancing lesion in right kidney, highly suggestive of renal abscess (Figure 1-A).

The intravenous antibiotics cefoxitin and isepamicin were initially administered. At first, the ultrasound-guided abscess aspiration failed because directly targeting the lesion was difficult. Instead, the patient continued medical treatment with piperacillin/tazobactam and ciprofloxacin. The patient maintained crizotinib due to its clinical benefit on NSCLC. During a CT scan two weeks later, there was an interval increase in size (3.5 to 4㎝) of the original right re- nal abscess and a newly extended abscess in the right posterior pararenal space (Figure 1-B). A USG aspiration and a percutaneous drain were performed simultaneously. Direct evaluations for microorganisms and cultures were all negative. Two weeks later, the extent of the right renal abscess had increased, requiring a second percutaneous drain (Figure 1-C). Decrease in the size of both lesions was found on the next examination; both drains were removed. Six months after discharge, CT scan revealed a remnant lesion on the right kidney and an extensive pleural metastasis of the NSCLC. Therefore, a substitutive agent, alectinib, is under consideration.