02 July 2026
: Case report 
Tacrolimus-Induced Thrombotic Microangiopathy in a Kidney Transplant Recipient After Treatment for Acute Allograft Rejection
Unusual clinical course, Challenging differential diagnosis, Unusual or unexpected effect of treatment, Diagnostic / therapeutic accidents, Adverse events of drug therapy, Clinical situation which can not be reproduced for ethical reasons
Yen-Hao Liao ABDEF 1*, Ming-Yi Huang DF 1DOI: 10.12659/AJCR.953247
Am J Case Rep 2026; 27:e953247
Table 1 Comprehensive biochemical evaluation undertaken to exclude alternative or secondary causes of thrombotic microangiopathy and microangiopathic hemolytic anemia.
| Hemogram | Blood biochemistry | Serology | ||||||
|---|---|---|---|---|---|---|---|---|
| Hemoglobin | 6.1 | g/dL | BUN | 43.7 | mg/dL | C3 | 80.6 | mg/dL |
| Hematocrit | 32.4 | % | Creatinine | 2.85 | mg/dL | C4 | 22.9 | mg/dL |
| Platelets | 46 | ×10/μL | AST | 15 | U/L | D-COOMBS | Negative | |
| Reticulocyte | 0.8 | %RBC | ALT | 15 | U/L | Haptoglobin | <7.06 | mg/dL |
| Fibrinogen | 284 | mg/dL | D. Bilirubin | 0.2 | mg/dL | CH50 Assay | 40.6 | U/mL |
| FDP | <5 | μg/mL | LDH | 252 | U/L | ADAMTS13 | 72 | % |
| D-dimer | 1652 | FEU ng/mL | Amylase | 50 | U/L | |||
| PT | 11.6 | sec | Lipase | 46 | U/L | Anti-Scl-70 | 5 (−) | AU/ml |
| INR | 1.1 | Sodium | 137 | mEq/L | Anti-Jo-1 | 4 (−) | AU/ml | |
| APTT | 27.3 | sec | Potassium | 3.7 | mEq/L | Phospholipid IgM | <6.25 | MPL units |
| Blood smear | Schistocytes (+2) | Calcium | 8.5 | mg/dL | Phospholipid IgG | 7.86 | GPL units | |
| Inorganic phosphorus | 2.9 | mg/dL | Anti-B2-GP1 IgM | <1.1 | CU | |||
| CMV-DNA Q-PCR | <34.5 | IU/mL | Uric acid | 5.3 | mg/dL | Cardiolipin IgG | 3 | CU |
| BKV DNA Q-PCR | Negative | CRP | 8.59 | mg/L | Cardiolipin IgM | 2.4 | CU | |
| Salmonella and Shigella | Negative | Homocysteine | 19.9 | μmol/L | ANA (IFA) | Negative | ||
| Influenza A+B Ag | Negative | Vitamin B12 | 338 | pg/mL | A-DSDNA | 14.3 | ||
| SARS-CoV-2 Ag | Negative | LA screening | 49.8 | sec | ||||
| LA Normal ratio | 1.4 | |||||||
| Abbreviations: ADAMTS13, a disintegrin and metalloproteinase with a thrombospondin type 1 motif member 13; A-DSDNA, anti-dsDNA antibody; ALT, alanine transaminase; ANA (IFA), antinuclear antibody (immunofluorescence assay); Anti-B2-GP1 IgM, anti-B2-glycoprotein-IgM; Anti-Scl-70, anti-topoisomerase I antibody; Anti-Jo-1, anti-histidyl tRNA synthetase antibody; APTT, activated partial thromboplastin time; AST, aspartate aminotransferase; BKV DNA Q-PCR, BK polyomavirus-DNA quantitative amplification test; BUN, blood urea nitrogen; C3, complement 3; C4, complement 4; Cardiolipin-IgM, anti-cardiolipin-IgM; Cardiolipin-IgG, anti-cardiolipin-IgG; CH50 Assay, complement activity total test; CMV-DNA Q-PCR, cytomegalovirus-DNA quantitative amplification test; CRP, C-reactive protein; D. Bilirubin, direct bilirubin; D-COOMBS, direct Coombs test; FDP, fibrin degradation products; INR, international normalized ratio; LA Normal ratio, lupus anticoagulant normalized ratio; LA screening, lupus anticoagulant screening; LDH, lactate dehydrogenase; Phospholipid IgG, anti-phospholipid antibody IgG; Phospholipid IgM, anti-phospholipid antibody IgM; PT, prothrombin time. | ||||||||