Tacrolimus toxicity in kidney transplant recipient after wedge liver resection: A case report and review of literature

doi:10.5527/wjn.v14.i4.111723

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World Journal of Nephrology

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Case Report

World J Nephrol. Dec 25, 2025; 14(4): 111723
Published online Dec 25, 2025. doi: 10.5527/wjn.v14.i4.111723

Tacrolimus toxicity in kidney transplant recipient after wedge liver resection: A case report and review of literature

Nuanjanthip Naiyarakseree, Thunyatorn Wuttiputhanun, Natavudh Townamchai, Methee Sutherasan, Yingyos Avihingsanon, Suwasin Udomkarnjananun

Nuanjanthip Naiyarakseree, Department of Medicine, Queen Savang Vadhana Memorial Hospital, Thai Red Cross Society, Si Racha 20110, Chon Buri, Thailand

Nuanjanthip Naiyarakseree, Thunyatorn Wuttiputhanun, Natavudh Townamchai, Yingyos Avihingsanon, Suwasin Udomkarnjananun, Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Krung Thep Maha Nakhon, Thailand

Thunyatorn Wuttiputhanun, Natavudh Townamchai, Yingyos Avihingsanon, Suwasin Udomkarnjananun, Excellence Center for Solid Organ Transplantation, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Krung Thep Maha Nakhon, Thailand

Thunyatorn Wuttiputhanun, Natavudh Townamchai, Yingyos Avihingsanon, Suwasin Udomkarnjananun, Center of Excellence Renal Immunology and Renal Transplantation, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Krung Thep Maha Nakhon, Thailand

Methee Sutherasan, Department of Surgery, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Krung Thep Maha Nakhon, Thailand

Suwasin Udomkarnjananun, Center of Excellence on Translational Research in Inflammation and Immunology, Department of Microbiology, Chulalongkorn University, Bangkok 10330, Krung Thep Maha Nakhon, Thailand

Author contributions: Naiyarakseree N and Udomkarnjananun S designed the study, collected data, created figure and table, and wrote the first draft of the manuscript; Wuttiputhanun T, Townamchai N, Sutherasan M, and Avihingsanon Y reviewed the manuscript; Udomkarnjananun S finalized the manuscript and supervised the project. All authors provided care for the patient in case report.

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 the authors report no relevant conflicts of interest for this article.

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).

Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

Corresponding author: Suwasin Udomkarnjananun, MD, PhD, Assistant Professor, Lecturer, Researcher, Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, No. 1873, Rama 4 Road, Pathumwan, Bangkok 10330, Krung Thep Maha Nakhon, Thailand. suwasin.u@gmail.com

Received: July 8, 2025
Revised: August 23, 2025
Accepted: October 21, 2025
Published online: December 25, 2025
Processing time: 168 Days and 16.9 Hours

Abstract

BACKGROUND

Tacrolimus is a key immunosuppressive agent used to prevent allograft rejection in kidney transplant recipients. Due to its narrow therapeutic index, careful monitoring is essential to avoid adverse effects, particularly neurotoxicity and nephrotoxicity. Hepatic metabolism is an important part of tacrolimus pharmacokinetics. This case report highlights the impact of liver resection on tacrolimus pharmacokinetics in a kidney transplant recipient.

CASE SUMMARY

A 61-year-old male with end-stage kidney disease underwent a living-unrelated donor kidney transplant at age 46 and has maintained a stable tacrolimus regimen for 15 years. He was later diagnosed with hepatocellular carcinoma and underwent an open wedge liver resection. Despite stable preoperative tacrolimus levels, he developed acute kidney injury and neurotoxicity (manifested as new-onset tremors and headache) postoperatively. Tacrolimus levels rose from 3.4 ng/mL before surgery to 19.5 ng/mL postoperatively, despite no changes in dosage. This increase was most likely due to reduced liver mass and function following resection, in addition to ischemic injury of the remaining liver parenchyma, leading to impaired drug metabolism and acute toxicity. Liver function tests showed transient abnormalities postoperatively, with transaminase levels peaking at 30 times the normal range before gradually returning to normal, coinciding with the decline in tacrolimus levels. The patient’s symptoms and acute kidney injury improved as tacrolimus concentration returned to normal.

CONCLUSION

This is the first reported case of acute tacrolimus neurotoxicity and nephrotoxicity in a kidney transplant recipient following liver resection. It highlights the critical need for vigilant therapeutic drug monitoring of tacrolimus after liver surgery to prevent severe adverse effects.

Keywords: Tacrolimus; Kidney transplant; Liver resection; Hepatectomy; Nephrotoxicity; Neurotoxicity; Case report

Core Tip: We report the first case of tacrolimus toxicity in a kidney-transplant recipient after wedge liver resection for hepatocellular carcinoma. Reduced liver mass and transient ischemic injury impaired metabolism of tacrolimus, a calcineurin inhibitor, causing rapid rises in trough concentration, acute kidney injury, and neurotoxicity that reversed with dose interruption. The case underscores the need for proactive therapeutic drug monitoring, early dose adjustment, and structured evaluation of postoperative acute kidney injury in transplant recipients undergoing hepatic surgery.