pISSN 3022-6783
eISSN 3022-7712

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Korean J Transplant 2022; 36(Suppl 1): S57-S57

Published online November 17, 2022

https://doi.org/10.4285/ATW2022.F-1755

© The Korean Society for Transplantation

Acute kidney injury in kidney transplant recipients with active SARS-CoV-2 infection due to drug interaction of tacrolimus and nirmatrelvir/ritonavir: three serial case reports

Haewon Park, Eun Jeong Ko, Byung Ha Chung, Chul Woo Yang

Department of Nephrology, The Catholic University of Korea Seoul St. Mary's Hospital, Seoul, Korea

Correspondence to: Eun Jeong Ko
E-mail: neat0505@gmail.com

Abstract

The mortality of SARS-CoV-2 infection of kidney transplant recipients (KTR) is higher than that of general population since immunocompromised condition. A novel oral protease inhibitor against SARS-CoV-2, nirmatrelvir (NR) is considered as a good option for outpatient-based antiviral treatment by reducing the risk of hospitalization and death. However, NR is metabolized mainly by cytochrome P450 3A4 (CYP3A4), which also metabolize calcineurin inhibitor (CNI). Hence, co-administration of these two drug results in drug interaction and increases serum tacrolimus (TAC) level almost 50 times, inducing acute CNI toxicity. Here we report serial three cases, two cases of NR without CNI dose reduction and one case of NR with cessation of CNI after telemedicine consultation with transplant physician. In case 1, since the patient did not aware of the risk of co-administration of NR and TAC, he took these two drugs together, which lead to acute kidney injury due to CNI toxicity. After discontinuation of TAC, renal function was recovered soon with normalized serum TAC concentration. Contrastively, in case 2, 3 days of simultaneous administration of NR and TAC led to sustained acute kidney injury even after discontinuation of TAC. Active intravenous hydration with cessation of TAC for several days improved renal function. However, in case 3, patient was informed to stop TAC with NR initiation in telemedicine consult, which resulted in harmless to renal function with stables serum TAC concentration nor any rejection event after 5 days of cessation of TAC. Therefore, special situation like SARS-CoV-2 pandemic, educating transplant recipient to discuss their new medication trough telemedicine with transplant specialist is very important to avoid acute graft injury.