Acute acyclovir neurotoxicity in a hemodialyzed child

Area of Science:

• Pediatric Nephrology
• Virology
• Pharmacology

Background:

• Epstein-Barr virus-induced lymphoproliferative disease (EBV-LPD) is a serious complication post-kidney transplantation.
• Management of EBV-LPD often involves antiviral therapy, such as acyclovir.
• End-stage renal failure (ESRF) necessitates careful drug dosing due to impaired excretion.

Observation:

• A 5-year-old kidney transplant recipient with EBV-LPD developed severe neurological symptoms, including coma, after initiating acyclovir therapy.
• Despite a reduced acyclovir dose due to concurrent hemodialysis for acute rejection, high serum acyclovir concentrations were observed.
• Neurological status improved rapidly after acyclovir discontinuation.

Findings:

• Acyclovir accumulation in pediatric patients with ESRF can lead to significant neurotoxicity.
• High post-dose serum acyclovir levels (182.5 microM) correlated with the onset of severe neurological symptoms.
• The neurotoxicity observed was reversible, with improvement noted within 2 days of stopping the medication.

Implications:

• Clinicians must exercise extreme caution when prescribing acyclovir to pediatric patients with ESRF.
• Standard dose adjustments for renal impairment may be insufficient to prevent acyclovir neurotoxicity in this population.
• Monitoring serum acyclovir concentrations and neurological status is crucial in pediatric transplant patients with renal failure receiving this antiviral agent.