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


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.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.