Seeking advice

[Guest guest]

Dear All;

My wife's father is 86 and suffering from end-stage kidney failure

after many years of diabetes. Recently he has developed edema (fluid

build-up) in his ankles, and with that, some gout (due to build up

of uric acid). He's taking diuretics to try to control the edema.

About April 27 his doctor also prescribed allopurinol (100 mg/day)

for the gout. About 1 week ago he began feeling very sick ... loss

of appetite, loss of taste, loss of interest in regular activities,

more sleepy. On Monday of last week we suggested that he stop taking

the allopurinol, and he did so. However, his health continued to

decline ... he developed jaundice and pruritus, and appeared to be

becoming dehydrated .... and so on Thursday we took him to the ER,

where they rehydrated him with an IV. Blood tests showed his

normally elevated kidney function tests, but unusually they also

showed elevated liver function tests; i.e. modestly elevated AST and

ALT, and highly elevated ALP (alkaline phosphatase (419)), elevated

bilirubin (5.1) and low albumin (2.9). Up until he had started

taking the allopurionol his liver function tests had always been

normal. Judy and I are suspecting that this may be allopurinol

hypersensitivity syndrome:

Korean J Hepatol. 2005 Mar;11(1):80-5.

A case of vanishing bile duct syndrome associated with

hypersensitivity to allopurinol.

Choi SH, Yang SH, Song YB, Kim HJ, Seo YT, Choi DS, Moon KH, Byun

JH, Yu ES.

Department of Internal Medicine, Veterans Hospital, Seoul, Korea.

Allopurinol is frequently used for the treatment of hyperuricemia

and gout. Sometimes, a life-threatening reaction develops, as is

illustrated by the following case report. We describe a 60-year-old

male patient who was treated with allopurinol because of

asymptomatic hyperuricemia, and he was presented with fever, skin

rash, eosinophilia, worsening renal function and vanishing bile duct

syndrome. In this report, we discussed vanishing bile duct syndrome

as a serious side effect of allopurinol, and we briefly reviewed the

etiology, prevention, and treatment modalities for vanishing bile

duct syndrome.

Publication Types:

Case Reports

PMID: 15788888

However, we are having difficulty convincing his doctors that this

may be the cause. A CAT scan did not reveal anything unusual. They

are wanting to do an ERCP early next week. We think that this is

potentially very dangerous for a man of his age with diabetes,

kidney failure, and now liver disease. We think that if it is

cholestasis caused by allopurinol, an ERCP may well prove to be

negative (cf. small duct PSC). We think that an ultrasound and an

MRCP would be less invasive. What do you all think? Are we being too

cautious? Any advice would be greatly appreciated.

Many thanks,

Dave

(father of (20); PSC 07/03; UC 08/03)