Clinical Case Scenario
A 26‑year‑old woman, five months post–renal transplant for autosomal dominant polycystic kidney disease, was admitted to the ICU with hematemesis, fever, and altered sensorium. On arrival, she was hypotensive (BP 84/65 mmHg) with severe anemia (Hb 5 g/dL).
After initial resuscitation and elective intubation for airway protection, she underwent CT angiography, which revealed multiple aneurysms in the coeliac and mesenteric arterial tree with active bleeding from the gastroduodenal artery (GDA). She underwent successful embolization of the GDA and was transferred back to the ICU for post‑procedural care.
She was empirically started on piperacillin–tazobactam and vancomycin. Blood cultures grew Enterococcus faecium, prompting escalation to meropenem, voriconazole, and trimethoprim–sulfamethoxazole for broader coverage. Given her recent transplant, the nephrology team advised continuation of immunosuppressants. All routine medications were continued except aspirin (withheld due to bleeding risk). Her whole blood tacrolimus trough level was subtherapeutic (5 ng/mL), so the dose was increased from 4 mg/day to 6 mg/day.
Her condition stabilized, and she was extubated on day 6.
On day 8, she developed a headache and severe hypertension (BP 180/100 mmHg). Neurological examination showed no focal deficits except for tremors. Later that evening, she developed visual disturbances and progressive coma.
Laboratory Findings
- Hb: 8.2 g/dL
- WBC: 12,000/µL
- CRP: 39 mg/L
- AST: 654 U/L, ALT: 345 U/L
- Bilirubin: 61 µmol/L
- Creatinine: 183 µmol/L (eGFR 37 mL/min/1.73m²)
- Potassium: 6.3 mmol/L
- pH: 7.18, pCO₂: 20 mmHg, HCO₃⁻: 14 mmol/L, BE: –9.3
- Phosphate: 0.6 mmol/L
What is the most appropriate next step in the definitive management of this patient.
