Motla V, Baig U, Mulloy L, Nakkar T, Beigh S, Gani I. Gemcitabine-sirolimus synergy associated thrombotic microangiopathy in a renal transplant recipient with mesenteric leiomyosarcoma: A case report. World J Transplant 2026; 16(2): 115114 [DOI: 10.5500/wjt.v16.i2.115114]
Corresponding Author of This Article
Imran Gani, MD, Associate Professor, Department of Nephrology, Hypertension and Transplant Medicine, Wellstar MCG Health, Augusta University, 1120 15th St, Augusta, GA 30912, United States. igani@augusta.edu
Research Domain of This Article
Transplantation
Article-Type of This Article
case-report
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Motla V, Baig U, Mulloy L, Nakkar T, Beigh S, Gani I. Gemcitabine-sirolimus synergy associated thrombotic microangiopathy in a renal transplant recipient with mesenteric leiomyosarcoma: A case report. World J Transplant 2026; 16(2): 115114 [DOI: 10.5500/wjt.v16.i2.115114]
Vishaal Motla, Laura Mulloy, Talal Nakkar, Shameem Beigh, Imran Gani, Department of Nephrology, Hypertension and Transplant Medicine, Wellstar MCG Health, Augusta University, Augusta, GA 30912, United States
Usman Baig, Independent Researcher, Atlanta, GA 30308, United States
Author contributions: Motla V contributed to initial draft writing, literature review; Baig U contributed to extensive literature review and compilation, manuscript editing; Mulloy L, Nakkar T, and Beigh S contributed to clinical management of the patient and feedback; Gani I contributed to clinical management of the patient, case report clinical information, case report and discussion compilation, final editing of manuscript; all authors read and approved the final manuscript.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: All authors declare that they have no conflict of interest to disclose.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Corresponding author: Imran Gani, MD, Associate Professor, Department of Nephrology, Hypertension and Transplant Medicine, Wellstar MCG Health, Augusta University, 1120 15th St, Augusta, GA 30912, United States. igani@augusta.edu
Received: October 13, 2025 Revised: November 22, 2025 Accepted: January 28, 2026 Published online: June 18, 2026 Processing time: 233 Days and 11.6 Hours
Abstract
BACKGROUND
Mesenteric leiomyosarcoma, a rare tumor originating from the smooth muscle of the mesentery, that may require treatment with gemcitabine based chemotherapy in advanced stages. Gemcitabine usage has been associated with the development of thrombotic microangiopathy, a risk which can be increased by concurrent use of sirolimus.
CASE SUMMARY
We present the case of a young Caucasian woman with a renal transplant who developed an aggressive leiomyosarcoma. While on gemcitabine, she was noted to have acute kidney injury. Biopsy of the renal allograft revealed histological findings consistent with thrombotic microangiopathy. Sirolimus was replaced with tacrolimus, and gemcitabine was discontinued. Despite treatment with eculizumab, the allograft function continued to decline, leading to graft failure, and the patient had to be started on renal replacement therapy.
CONCLUSION
This case highlights the possible synergy of gemcitabine and sirolimus in the pathogenesis of de novo thrombotic microangiopathy.
Core Tip: Thrombotic microangiopathy represents a rare yet serious complication in renal transplant patients, potentially causing rapid loss of allograft function. Various medications, including gemcitabine and sirolimus, have been implicated in its pathogenesis. Even with discontinuation of causative agents and anticomplement therapy, allograft function may progressively worsen.
