A 58-Year-Old Man With a Rash and Elevated Creatinine Levels

F. Gerald Wade, MD; Elie Ghoulam, MD; Thomas Fay, MD; George Vasquez Rios, MD; Kamran Qureshi, MD

Disclosures

October 02, 2019

Physical Examination and Workup

On examination, the patient's vital signs were within normal limits. A physical examination revealed normal abdominal findings. His knees had full range of motion bilaterally and were without crepitus or effusion. Lower-extremity examination revealed scattered erythematous, hyperpigmented papules on both legs. Otherwise, physical examination findings were unremarkable.

Repeat laboratory assessment was notable for the following:

  • Creatinine level: 2.1 mg/dL (posttransplant creatinine baseline level, 1.36 mg/dL)

  • Blood urea nitrogen level: 22 mg/dL (typical reference range, 7-20 mg/dL)

  • Total protein: 7 g/dL (reference range, 6-8.3 g/dL)

  • Albumin level: 3.2 g/dL (reference range, 3.4-5 g/dL)

Dipstick urinalysis with microscopic examination revealed > 100 red blood cells per high-power field and 1+ protein.

The following day, the patient's tacrolimus trough level was supratherapeutic, at 11 ng/mL (reference range, 5-10 ng/mL). The tacrolimus dose was adjusted, and the patient was instructed to follow up at a clinic in 1 week. At that visit, the patient's creatinine level had increased to 2.8 mg/dL and his tacrolimus level was 9 ng/mL. In addition, his aspartate aminotransferase and alanine aminotransferase levels were now elevated, at 68 U/L (reference range, 5-34 U/L) and 66 U/L (reference range, 0-55 U/L), respectively.

Over the course of another week, while workup for the patient's acute kidney injury and HCV was pursued, his creatinine level continued to rise (3.1 mg/dL). Additional laboratory investigation revealed the following:

  • BK virus: negative

  • Tacrolimus level: 9 ng/mL

  • HCV RNA: 35,591,559 copies/mL

  • HCV genotype: 1a

  • C4 level: 6 mg/dL (reference range, 15-57 mg/dL)

  • C3 level: 86 mg/dL (reference range, 82-193 mg/dL)

  • Antinuclear antibody (Ab): positive

  • Anti-dsDNA Ab: negative

  • Erythrocyte sedimentation rate: 47 mm/h (reference range, 0-30 mm/h)

  • C-reactive protein level: 27 mg/dL (reference range, < 0.5 mg/dL)

  • Rheumatoid factor : 63 IU/mL (reference range, < 14 IU/mL)

  • Anti-RNP Ab: < 10 U (reference range, < 10 U)

  • Antihistone Ab: negative

  • Anti-Smith Ab: negative

Renal biopsy of the graft kidney is shown in Figures 2 and 3.

Figure 2.

Figure 3.

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