Tacrolimus (FK 506)-induced thrombotic thrombocytopenic purpura after ABO mismatched second liver transplantation: salvage with plasmapheresis and prostacyclin

We report the course of thrombotic thrombocytopenic purpura (TTP) in a pati ent receiving tacrolimus (FK506) immunosuppression for an ABO mis-matched s econd liver graft. A Chinese woman with fulminant hepatitis-B reactivation failed a living-related orthotopic liver transplantation (OLT) due,to porta l vein thrombosis. An ABO mismatched cadaveric OLT (group A to 0) was perfo rmed, with peri-operative plasmapheresis to reduce anti-A hemagglutinin tit ers. On day 30, she developed,'fever, hemolysis, thrombocytopenia and neuro logic dulling. Prominent microangiopathic features in peripheral blood film , and characteristic brain lesions on magnetic resonance imaging confirmed TTP. She responded initially to intensive plasma-pheresis with cryosupernat ant replacement, and withdrawal of FK506. An attempted reintroduction of FK 506 for threatened rejection led to TTP exacerbation. This was controlled w ith prolonged plasmapheresis and a ten-day infusion of prostacyclin. Immuno suppression was changed to mycophenolate mofetil. By day 53, the peripheral film and lactate dehydrogenase level had returned to baseline and plasmaph eresis was stopped. (C) 2000, Ferrata Storti Foundation.