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Received May 9, 2017; Accepted Jul 24, 2017
This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
1. Introduction
Tacrolimus and cyclosporine are widely used calcineurin inhibitors (CNIs) with a narrow therapeutic window and multiple drug-drug interactions [1]. They have the potency to induce renal failure due to acute arteriolopathy. Moreover, CNIs lead to altered tubular function, resulting in an impaired renal concentrating ability [2].
Within this context, we report the case of a pediatric liver transplant recipient who suffered acute polyuric renal failure leading to severe dehydration during a diet with high renal solute load.
Informed consent was obtained from the parents for publication of this report.
2. Case Presentation
A 14-month-old girl with a body weight of 7.7 kg was admitted to our pediatric intensive care unit (PICU) in acute polyuric renal failure including severe hypernatremia, hyperchloremia, hyperkalemia, hyperuricemia, and metabolic acidosis. Clinically she was irritable and appeared only mildly dehydrated. Her heart rate on admission was 150 beats per minute with an arterial blood pressure of 83/43 (63) mmHg. Renal ultrasound on admission revealed bilateral nephrocalcinosis type IIa. Her laboratory findings on admission are summarized in Table 1. The girl was treated with tacrolimus after liver transplantation 7 months prior to admission for extrahepatic biliary atresia. Renal ultrasound before liver transplantation showed a normal finding. She was discharged home from a former hospital stay 8 days prior to this admission with the recommendation for 800 ml Nutrini Energy MultiFibre® (Table 2) a day in addition to complementary feeding. Against medical advice she drank no additional water. Therefore, her calculated water deficit over the last 8 days was 23.6% of her body weight (Table 3). In PICU the high protein diet was interrupted and the girl was intravenously rehydrated. The average diuresis in the first 12 hours after admission was 8.1 ml/kg/hour. Additionally, bicarbonate was administered and the antihypertensive therapy with enalapril was paused for 2 days. Under...