Cyclosporine-associated thrombotic microangiopathy during daclizumab induction: A suggested therapeutic approach

A woman on daclizumab developed thrombotic microangiopathy secondary to cyc losporine after a living-unrelated kidney transplant. Despite cyclosporine discontinuation, hemolysis persisted. The second dose of daclizumab was pos tponed 24 h, and after a maximum of two sessions of plasmapheresis (to avoi d further modifications in daclizumab schedule) with plasma exchange, dacli zumab was administered. Plasma infusions were prescribed until D-dimer and fibrinogen-degradation products normalized; thereafter, FK-506 was started without recurrence of the hemolytic picture and renal function restored. Th is observation suggests that in patients on daclizumab who develop thrombot ic microangiopathy secondary to immunosuppressants, if discontinuation of t he offending drug is unsuccessful, plasmapheresis with plasma exchange can be performed when the lowest levels of daclizumab exist, followed by dacliz umab infusion. Plasma prescription must be continued thereafter until D-dim er and figrinogen-degradation products normalize. However, if hemolysis per sists when daclizumab levels are high, plasma infusions are useful and plas mapheresis avoided. FK-506 administration did not result in recurrence of h emolysis during daclizumab induction. Copyright (C) 2001 S. Karger AG. Base l.