Clopidogrel
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Thrombotic microangiopathy presenting as haemolytic uraemic syndrome: case report A 44-year-old man developed thrombotic microangiopathy (TMA) presenting as haemolytic uraemic syndrome (HUS) after treatment with clopidogrel for unstable angina. The man presented with 1 week history of oliguria, malaise, anorexia, feet oedema. One month prior, he was hospitalised for unstable angina and was treated conservatively with clopidogrel, beta blocker, statin and nitrate [routes and dosages not stated; drug names not specified]. At that time, his haemoglobin was 12.0 g/dL and serum creatinine was 1.3 mg/dL. After 1 month, he presented with pale appearance and pedal oedema. His BP was 124/80mm Hg and pulse rate was 90 /min. Laboratory investigations revealed the following: AST 76 IU/L, ALT 40 IU/L, LDH 1600 IU/L, haemoglobin 7.2 g/dL, blood urea 80 mg/dL, serum creatinine 5.2 mg/dL, total leucocyte count 10 x 103/mL, platelet count 98 x 103/mL, total and direct bilirubin 2.4 mg/dL and 0.5 mg/dL. Significant number of schistocytes were seen in peripheral blood smear test. Absolute reticulocyte count was noted to be 4.0%. Urine examination exhibited 3+ albumin, 8-10 RBC/hpf and 6‑8 pus cells/hpf. Spot urine protein creatinine ratio was observed to be 4.5. Clopidogrel was discontinued and after 5 days, renal biopsy was performed considering rapidly progressive renal failure (RPRF). He was treated with IV methylprednisolone, followed by steroids. Renal biopsy showed 16 glomeruli, most of them revealed wrinkling of basement membranes and ischaemic thickening indicating mesangiolysis. A few neutrophils were seen along with mild to moderate interstitial infiltration of lymphocytes. Interstitial fibrosis associated with mild tubular atrophy was observed involving 20% of the cortex studied. A few arterioles exhibited fibrin thrombi with luminal occlusion. Interlobular arteries showed myxoid change of the media and intimal fibrosis. The man was diagnosed with TMA and was treated with tapering doses of steroids with intermittent plasma infusions. By day 10, his haematological parameters and serum LDH levels were stabilised, along with gradual improvement in his urine output. Within 6 weeks, his serum creatinine level decreased to 2.1 mg/dL and decreased further to 1.8 mg/dL by the end of 16 weeks. Due to prominent renal involvement and mild thrombocytopenia, he was diagnosed with HUS, which was confirmed by renal biopsy. Concomitant therapy with statin was also stated as a contributing factor in the development of HUS. Etta P, et al. Clopidogrel induced thrombotic microangiopathy successfully treated with conservative approach. Indian Journal of Nephrology 30: 209-210, No. 3, 2020. 803497044 Available from: URL: http://doi.org/10.4103/ijn.IJN_194_19
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Reactions 22 Aug 2020 No. 1818
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