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Updated: Nov 22, 2025
Murine Kidney Transplant Technique
Published on: October 20, 2015
Small intestinal thrombotic microangiopathy following kidney transplantation diagnosed by balloon-assisted
Masafumi Nishio1, Kingo Hirasawa1, Jun-Ichi Teranishi2
1Division of Endoscopy (Masafumi Nishio, Kingo Hirasawa, Yuichiro Ozeki, Atsushi Sawada, Ryosuke Ikeda, Takehide Fukuchi, Ryosuke Kobayashi, Makomo Makazu, Chiko Sato).
Abstract:
Thrombotic microangiopathy (TMA) is a serious complication following kidney transplantation. Although intestinal TMA is a major organ injury and causes abdominal pain, diarrhea and bloody stools, the clinical and endoscopic characteristics of small intestinal TMA remain unclear. Here, we report a drug-induced small intestinal TMA, which did not meet the laboratory-defined TMA criteria but was diagnosed by balloon-assisted enteroscopy (BAE). A 32-year-old woman who underwent kidney transplantation at the age of 10 years complained of abdominal pain, diarrhea and bloody stools one month after starting everolimus (EVE) as an immunosuppressant. Although she did not meet the diagnostic criteria for TMA serologically, BAE revealed a circumferential ulcer in the jejunum, and the pathological findings of a biopsy specimen showed microvascular thrombi, compatible with intestinal TMA. Her symptoms improved upon the discontinuation of EVE, demonstrating that EVE can cause drug-induced intestinal TMA. The present case suggests that BAE should be performed when abdominal pain, diarrhea, and bloody stools occur in patients receiving immunosuppressive medication following kidney transplantation, even if there is no evidence of TMA according to the laboratory definition.
Insights
Everolimus can cause drug-induced small intestinal thrombotic microangiopathy (TMA) in kidney transplant recipients, presenting with gastrointestinal symptoms. Balloon-assisted enteroscopy aids diagnosis even without serological TMA evidence.
Area of Science:
- Nephrology
- Gastroenterology
- Transplantation Medicine
Background:
- Thrombotic microangiopathy (TMA) is a severe complication post-kidney transplantation.
- Small intestinal TMA presents with abdominal pain, diarrhea, and bloody stools, but its clinical and endoscopic features are not well-defined.
Observation:
- A kidney transplant recipient developed abdominal pain, diarrhea, and bloody stools after initiating everolimus (EVE).
- Laboratory TMA criteria were not met, yet balloon-assisted enteroscopy (BAE) revealed a jejunal ulcer.
Findings:
- Biopsy of the jejunal ulcer showed microvascular thrombi, confirming intestinal TMA.
- Discontinuation of EVE led to symptom improvement, establishing a causal link.
Implications:
- This case highlights everolimus as a potential cause of drug-induced intestinal TMA.
- BAE is recommended for diagnosing intestinal TMA in transplant patients with GI symptoms, even if serological TMA markers are absent.
