Ribavirin-induced anaemia reduced tacrolimus level in a hepatitis C patient receiving haemodialysis.

A 37-year-old man with hepatitis C virus (HCV) genotype 3A developed renal failure. In 2007, the patient received a renal transplant and started receiving tacrolimus (Tac); the transplant subsequently failed. In April 2015, the patient restarted haemodialysis and in May initiated sofosbuvir 400 mg and ribavirin 400 mg daily. Baseline Tac level was 6.6 ng/mL and haemoglobin (Hb) was 10.3 g/dL. The patient then left the country for vacation and Hb was found to be dramatically low at 3.7 g/dL on return on 5 August. Ribavirin was put on hold, while darbepoetin dose was increased. On 23 August, Tac level was found undetectable; hence, dosage was increased. Hb eventually bounced back to >10 g/dL in October and Tac to 7.2 ng/mL; ribavirin was restarted at 200 mg three times weekly. HCV RNA level was undetectable at 3 months and remained undetectable 12 weeks after therapy finished.