Severe Complications from an Unexpectedly High Serum Mycophenolic Acid Concentration in a Patient with Renal Failure Secondary to Lupus Nephritis: A Case Report

Abstract

Mycophenolate mofetil (MMF) is used widely to treat lupus nephritis and is considered safer than other immunosuppressive drugs. Reports on severe complications related to MMF are sparse. We report a case of a patient with lupus nephritis in whom severe complications were possibly caused by MMF. The patient was a 17-year-old girl who received a diagnosis of lupus nephritis at the age of 14 years and had been taking steroid and immunosuppressive agents since then. One week after starting MMF 1 g/day instead of mizoribine owing to symptom relapse and serologic data deterioration, she presented with seizure, accompanied by leukopenia, thrombocytopenia, and renal failure. We discontinued MMF because she had extremely high serum mycophenolate acid concentration (88 µg/mL). A few weeks later, she recovered without any complications and was discharged. Although rare, clinicians should be aware that serum mycophenolate acid concentration may become extremely high in the setting of acute kidney injury. In such circumstances, they should perform serum concentration monitoring to avoid possible adverse events.

Acute Mycophenolate Mofetil Overdose Managed Conservatively

“…A case report by Doi et al reported seizures, leukopenia, thrombocytopenia, and acute renal failure in a 17-year-old girl with lupus nephritis who took 1 g of MMF daily for one week. But her symptoms resolved in a few weeks without complications after the discontinuation of the drug [ 10 ]. In a 40-year-old female kidney recipient under maintenance dose of MMF, acute ingestion of 25 g of MMF resulted in moderate leukopenia [ 11 ].…”

Severe Mycophenolate Intoxication in a Solid Organ Transplant Recipient—No Intervention Actually Needed

“…The widespread use of MMF caries the risk of being deliberately misused by patients for self-harms and, if trough concentrations are not measured on a regular basis, may lead to intoxication even on recommended doses. 9 In severe acute overdose situations, expected events would be GI problems, leukopenia, anemia, and thrombocytopenia and if long-lasting, possible overimmunosuppression leading to increased susceptibility to infections. With timely withdrawal of additional MMF/EC-MPS doses, rapid initiation of EHC inhibiting therapy, it is possible to reduce and sometimes avoid excessive bone marrow depression, and other adverse outcomes may be minimized.…”

“…The symptoms were initially thought to be lupus related but turned out to be due to severe MPA intoxication with a measured concentration of 88 mg/L. 9 The patient experienced a complete recovery without any complications after MMF withdrawal.…”

TAFRO syndrome was effectively treated with an inexpensive novel scheme: A case report

“…MCD may cause multiple lymph nodes enlargement and organs dysfunction 2 . Approximately 50% of patients with MCD who are negative for HIV and HHV8 comprise a subgroup that has been termed as idiopathic MCD (iMCD) 3 . As a particular subtype of iMCD, TAFRO syndrome was extremely rare to be reported, which was characterized by thrombocytopenia [T], anasarca [A], fever [F], renal failure [R], and organomegaly [O].…”