Nebulized Pentamidine-Induced Acute Renal Allograft Dysfunction

Acute kidney injury (AKI) is a recognised complication of intravenous pentamidine therapy. A direct nephrotoxic effect leading to acute tubular necrosis has been postulated. We report a case of severe renal allograft dysfunction due to nebulised pentamidine. The patient presented with repeated episodes of AKI without obvious cause and acute tubular necrosis only on renal histology. Nebulised pentamidine was used monthly as prophylaxis for Pneumocystis jirovecii pneumonia, and administration preceded the creatinine rise on each occasion. Graft function stabilised following discontinuation of the drug. This is the first report of nebulized pentamidine-induced reversible nephrotoxicity in a kidney allograft. This diagnosis should be considered in a case of unexplained acute renal allograft dysfunction. 1. Background Drug-induced nephrotoxicity is a potential cause of acute kidney allograft dysfunction in the early posttransplant period [1]. The most common culpable medications are calcineurin inhibitors [2], as other agents associated with nephrotoxicity are generally avoided in this setting. However, there are typically several different new drugs prescribed to patients following kidney transplantation, including prophylactic antimicrobial agents. Given the higher immunosuppression load in the early post transplant period, there is an increased risk of opportunistic infections like Pneumocystis jirovecii pneumonia (PJP). The European Best Practice Guidelines (EBPG) recommend at least four months of PJP prophylaxis postrenal transplantation [3], while the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines suggest 3–6 months [4]. Both guidelines advocate additional prophylaxis during and following the treatment of acute rejection. The recommended treatment of choice is cotrimoxazole. Nebulized pentamidine is an alternative for those patients who are intolerant of cotrimoxazole. Acute kidney injury (AKI) has been reported as a complication of intravenous pentamidine therapy. There is a single case report of nebulised pentamidine causing an adverse effect on renal function in native kidneys. We present a case of severe reversible acute kidney allograft dysfunction attributed to the use of nebulized pentamidine therapy. 2. Case Report A 65-year-old woman with end-stage renal disease of unknown aetiology received a renal transplant, from her thirty-two-year-old daughter, after five years of dialysis therapy. Past medical history was significant for hypertension, ischaemic heart disease, and essential thrombocytosis. The kidney was mismatched at B57