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First Reported Case of Rhabdomyolysis Associated with Concomitant Use of Cyclosporin, Diltiazem, and Simvastatin

Fuah KW, Lim C

Indian J Nephrol, 2020 11 07;31(2):173-175.

PMID: 34267441 DOI: 10.4103/ijn.IJN_5_20

Rhabdomyolysis is a syndrome with a wide range of symptoms ranging from asymptomatic raised serum creatinine kinase to life-threatening metabolic disturbances and acute kidney injury. A careful history taking and high clinical suspicion on drug-drug interaction are crucial to identify the etiology of rhabdomyolysis. Here, we present a case of rhabdomyolysis due to a rare drug-to-drug interaction of simvastatin, diltiazem, and cyclosporin in a patient with IgA nephropathy. Early renal replacement therapy was initiated, and the insulting agents were withheld. Despite the metabolic disturbances were corrected, the patient succumbed to possible venous thromboembolism event during the prolonged hospital stay. Therefore, heightened awareness is required in dealing with patients with glomerulonephritis who are frequently prescribed on polypharmacy, in order to reduce unwarranted adverse events.

Fulltext Erythema nodosum masking nephrogenic systemic fibrosis as initial skin manifestation

Fuah KW, Lim CTS

BMC Nephrol, 2017 Jul 24;18(1):249.

PMID: 28738858 DOI: 10.1186/s12882-017-0666-7

BACKGROUND: Nephrogenic systemic fibrosis (NSF) is a complication of the gadolinium-based contrast agent used in imaging studies. It is typically characterised by hard, erythematous and indurated skin plaques with surrounding subcutaneous oedema. Distinct papules and subcutaneous nodules can also be seen. Fibrocytes in NSF are immunohistochemically positive for CD34.

CASE PRESENTATION: We present a case of NSF occurred after gadolinium exposure in which the initial presentation mimics an erythema nodosum (EN)-like picture. An initial skin biopsy showed EN. Subsequently the patient developed progressive skin and joints contracture. A repeated skin biopsy done three months later confirmed the diagnosis of NSF. As far as we are aware, this is the second reported case of NSF that mimicked the presentation of EN in the early phase of the disease.

CONCLUSIONS: The appearance of EN-like disease can be one of the early manifestations of NSF. We hope that early recognition of this unusual presentation can alert the physician or nephrologist to the potential diagnosis of NSF.

Fulltext Renal-limited AL amyloidosis - a diagnostic and management dilemma

Fuah KW, Lim CTS

BMC Nephrol, 2018 11 06;19(1):307.

PMID: 30400895 DOI: 10.1186/s12882-018-1118-8

BACKGROUND: Amyloidosis is a disorder caused by extracellular tissue deposition of insoluble fibrils which may result in a wide spectrum of symptoms depending upon their types, sites and amount of deposition. Amyloidosis can be divided into either systemic or localized disease.

CASE PRESENTATION: We present a case of a middle-aged gentleman who presented with persistent nephrotic syndrome with worsening renal function. Repeated renal biopsies showed the presence of renal-limited AL amyloidosis. Systemic amyloidosis workup was unremarkable apart from a slightly raised band of IgG lambda level with no associated immunoparesis. The nephrotic syndrome and renal histology did not improve over a 3-year period despite being given two courses of chemotherapies.

CONCLUSION: We hope that early recognition of this unusual localised presentation of renal- limited AL Amyloidosis and its poor response to conventional treatment can alert the nephrologist to the potential existence of this rare condition.

Fulltext Seizure induced by tranexamic acid in a patient with chronic kidney disease on maintenance dialysis

Fuah KW, Lim CTS, Pang DCL, Wong JS

Saudi J Kidney Dis Transpl, 2018 2 20;29(1):207-209.

PMID: 29456232 DOI: 10.4103/1319-2442.225177

Tranexamic acid (TXA) is an antifibrinolytic agent commonly used to achieve hemostasis. However, there have been a few case reports suggesting that high-dose intravenous TXA has epileptogenic property. In patients with renal impairment, even administering the usual recommended dose of TXA can induce seizure episodes. We present here a patient on hemodialysis who developed seizures after receiving two doses of TXA over 5 h period.

Clinical course of Klebsiella variicola peritonitis in end-stage kidney disease patients receiving peritoneal dialysis

Arimuthu DA, Fuah KW, Lim CTS

BMJ Case Rep, 2024 Nov 07;17(11).

PMID: 39510614 DOI: 10.1136/bcr-2024-262696

Klebsiella variicola is part of the K. pneumoniae complex and has been recently identified to have pathogenic properties. Emerging reports show that it can cause bloodstream, respiratory and urinary tract infections. It has been shown to be an important causative agent in immunocompromised individuals. We report here three cases of K. variicola peritonitis encountered in our peritoneal dialysis patients.

Osmotic nephropathy triggered by sodium-glucose cotransporter 2 inhibitors in a patient with IgA nephropathy

Lim CTS, Fuah KW, Chew CL

BMJ Case Rep, 2025 Mar 25;18(3).

PMID: 40132923 DOI: 10.1136/bcr-2024-263859

A woman with biopsy-confirmed IgA nephropathy (IgAN) presented with persistent non-nephrotic range proteinuria and stage 3b chronic kidney disease (CKD). Her treatment regimen included the initiation of a sodium-glucose cotransporter 2 inhibitor (SGLT2i), dapagliflozin, starting at 5 mg daily and later titrated to 10 mg daily after several months. Following the dose increase, she developed significant acute-on-chronic kidney injury. Despite discontinuing the SGLT2i, her renal function did not recover. A subsequent kidney biopsy revealed findings consistent with osmotic tubulopathy with worsening IgAN. This case highlights a rare but important adverse effect of SGLT2i, particularly in patients with pre-existing CKD. While initial expert guidance advised against routine renal function monitoring to avoid premature discontinuation due to the expected transient rise in creatinine, evolving clinical experience suggests that individualised monitoring may be necessary in high-risk patients. Future guidelines will need to clarify how to balance these considerations to optimise patient outcomes.

Rare occurrence of anticoagulant-related nephropathy in a patient with mechanical mitral valve replacement

Then RF, Arimuthu DA, Fuah KW, Lim CTS

BMJ Case Rep, 2025 Mar 25;18(3).

PMID: 40132918 DOI: 10.1136/bcr-2024-262680

Anticoagulant-related nephropathy (ARN) is a rare type of acute kidney injury (AKI) caused by excessive anticoagulation with warfarin or other anticoagulants, such as direct oral anticoagulants (DOACs). We describe a case of a woman in her 50s with a background history of mitral valve replacement who was on warfarin and admitted for AKI, haematuria and a supratherapeutic international normalised ratio (INR) level. A renal biopsy showed red cell casts in the renal tubules, and a diagnosis of ARN was made. Her treatment included the temporary withdrawal of warfarin. Her renal function improved, and warfarin was restarted before she was discharged. This case highlights the importance of maintaining a high clinical suspicion when diagnosing ARN in patients who present with AKI and supratherapeutic INR levels.

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