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

Sep 28, 2026

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Tacrolimus is a key immunosuppressant for preventing allograft rejection in kidney transplant recipients, but its narrow therapeutic index requires close monitoring to avoid neurotoxicity and nephrotoxicity. This case report describes a 61-year-old man with long-term tacrolimus stability who developed postoperative acute kidney injury and neurotoxicity after open wedge liver resection for hepatocellular carcinoma. Tacrolimus trough levels rose markedly without dose change, most consistent with reduced hepatic mass and transient ischemic injury impairing metabolism. Symptoms improved as concentrations normalized.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages9

Reading Time23 min

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Abstract

Background

Case Summary

Conclusion

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Citation

| W | J | N | World Journal of
Nephrology | | --- | --- | --- | --- | Submit a Manuscript: [https://www.f6publishing.com](https://www.f6publishing.com) World J Nephrol 2025 December 25; 14(4): 111723 DOI: 10.5527/wjn.v14.i4.111723 ISSN 2220-6124 (online) CASE REPORT 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 Specialty type: Urology and nephrology Provenance and peer review: Unsolicited article; Externally peer reviewed. Peer-review model: Single blind Peer-review report’s classification Scientific Quality: Grade A, Grade A Novelty: Grade A, Grade A Creativity or Innovation: Grade A, Grade B Scientific Significance: Grade A, Grade B P-Reviewer: Chakrabarti SS, MD, Professor, India Received: July 8, 2025 Revised: August 23, 2025 Accepted: October 21, 2025 Published online: December 25, 2025 Processing time: 168 Days and 19.9 Hours 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 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](suwasin.u@gmail.com) 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 pharma- WJN [https://www.wjgnet.com](https://www.wjgnet.com) 1 December 25, 2025 Volume 14 Issue 4 Naiyarakseree N et al. Tacrolimus toxicity after liver resection cokinetics 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

FAQs

Why is tacrolimus toxicity a concern in kidney transplant recipients?

Tacrolimus has a narrow therapeutic index, so small changes in exposure can lead to adverse effects such as neurotoxicity and nephrotoxicity. Careful therapeutic drug monitoring is essential to avoid these complications.

What surgery was involved and how did it relate to tacrolimus levels?

The patient underwent an open wedge liver resection for hepatocellular carcinoma. Despite stable preoperative tacrolimus levels and no dosage change, postoperative trough levels increased substantially, consistent with impaired hepatic metabolism after reduced liver mass and transient ischemic injury.

What were the clinical outcomes after tacrolimus exposure increased?

The patient developed acute kidney injury and neurotoxicity, including new-onset tremors and headache. Clinical improvement occurred as tacrolimus concentrations returned to normal, with dose interruption mentioned in the core tip.

Sep 28, 2026

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