A Post–Liver Transplant Girl With Recurrent Cramps in the Legs

reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page A 17-year-old girl was diagnosed with liver dysfunction during a regular medical follow-up for a previous liver transplantation. She had undergone the Kasai procedure (hepatoportoenterostomy) on the 73rd day after birth for biliary atresia, followed by living-donor liver transplan-tation from her father at 12 years of age because of liver cirrhosis associated with gigantic focal nodular hyper-plasia. Although she had been well controlled on a maintenance dose of tacrolimus alone (1 mg/day), treatment with tacrolimus had been discontinued on her own judgment. A laboratory examination showed serum aspartate aminotransferase levels of 747 IU/L and alanine amino-transferase levels of 994 IU/L. She was clinically diagnosed as having an acute rejection reaction and was admitted to our hospital. Her liver function recovered by 1 g methylprednisolone pulse therapy, followed by oral prednisolone (PSL) and an increase in tacrolimus to 3.5 mg/day, with a monitoring therapeutic dose. Although both PSL and tacrolimus were gradually reduced to 10 mg/day and 2 mg/day, respectively, she first complained of recurrent cramps in the legs. In a few weeks she complained of being thirsty, polydipsia, and polyuria, even a month after the acute rejection reaction. She had no familial history of diabetes mellitus (DM) or was not obese. Laboratory findings were as follows: fasting blood sugar 29.6 mmol/L, HbA1c (hemoglobin A1c) 11.2%, immune reactive insulin 23.7 µU/mL, tacrolimus trough level 8.4 ng/mL. Her liver function, renal function , blood level of electrolytes, and blood gas assessment were all within normal ranges. A urinalysis showed severe glycosuria and was negative for ketone bodies. Her initial therapy consisted of metformin (500 mg/ day), a therapeutic diet (1800 kcal/day), and mycophe-nolate mofetil (500 mg/day) as a steroid-tacrolimus sparing agent, followed by a rapid reduction in steroid and maintenance of tacrolimus on a low therapeutic level (2 mg/day; Figure 1). Her symptoms disappeared within a month after the introduction of antidiabetic treatment. Her HbA1c levels gradually decreased to the normal range (<5.8%) within 4 months without acute or chronic rejection reactions. She no longer needed anti-diabetic therapy 6 months from her initial treatment for DM. She is currently well and takes only low-dose tacrolimus (1 mg/day) with around 5 ng/mL as the target trough level without any recurrence of a rejection reaction or DM. Discussion A wide …