肾移植后抗排异治疗期间腹泻致他克莫司血药谷浓度升高

Increased blood trough concentration of tacrolimus due to diarrhoea during the anti-rejection therapy after renal transplantation

1例31岁男性患者行异体肾移植术后接受三联抗排异治疗(他克莫司3mg、1次/12h,麦考酚钠肠溶片720mg、2次/d,醋酸泼尼松龙片80mg、1次/d)。术后第5天患者的他克莫司血药谷浓度为4.90μg/L。术后第7天,患者出现5次水样便,他克莫司谷浓度为8.62μg/L,临床药师考虑腹泻为肾移植术后反应,他克莫司谷浓度升高可能为腹泻所致。加用蒙脱石散3.0g、3次/d口服,同时给予莫西沙星氯化钠注射液0.4g静脉滴注、1次/d。术后第12天,患者出现8次水样便,他克莫司血药谷浓度升至13.78μg/L,将他克莫司剂量调整为3mg/d(早8时2mg,晚8时1mg);术后第14天,患者腹泻减轻(3次水样便),他克莫司血药谷浓度为20.67μg/L,将他克莫司剂量减为1mg、1次/12h;术后第18天,患者未出现腹泻,他克莫司血药谷浓度降至9.63μg/L,患者病情稳定出院。出院后调整他克莫司剂量为2mg、1次/12h。此后3次复诊,患者的他克莫司血药谷浓度分别为9.12、9.23和为9.15μg/L。

A 31-year-old male patient received triple anti-rejection therapy (tacrolimus 3 mg once per 12 hours, mycophenolate sodium enteric-coated tablets 720 mg twice daily, and prednisolone acetate tablets 80 mg once daily) after his renal allotransplantation. On day 5 after operation, the blood trough concentration of tacrolimus was 4.90 μg/L. On day 7, he developed 5 watery stools and the blood trough concentration of tacrolimus was 8.62 μg/L. The clinical pharmacist considered the diarrhea was the postoperative response to renal allotransplantation and the increased blood trough concentration of tacrolimus might be caused by diarrhea. Montmorillonite powder 3.0 g thrice daily orally and an IV infusion of moxifloxacin sodium chloride injection 0.4 g once daily were given. On day 12 after operation, the patient experienced 8 watery stools and his blood trough concentration of tacrolimus increased to 13.78 μg/L. The dose of tacrolimus was adjusted to 2 mg and 1 mg at 8: 00 and 20: 00 respectively. On day 14 after operation, the patient's diarrhea relieved (3 watery stools) and the blood trough concentration of tacrolimus was 20.67 μg/L. The dose of tacrolimus was adjusted to 1 mg once per 12 hours. On day 18 after operation, no diarrhea occurred in the patient and the blood trough concentration of tacrolimus decreased to 9.63 μg/L. The patient was discharged in a stable condition. The post-discharge dose of tacrolimus was adjusted to 2 mg per 12 hours. The blood trough concentrations of tacrolimus in his 3 return visits were 9.12, 9.23, and 9.15 μg/L, respectively.