acute myelogenous leukemia secondary to heart transplantation. Transplantation 2000; 70(4): 688. 4. Slavin S, Nagler A, Naparstek E, et al. Nonmyeloablative stem cell trans- plantation and cell therapy as an alternative to conventional bone marrow transplantation with lethal cytoreduction for the treatment of malignant and nonmalignant hematologic diseases. Blood 1998; 91: 756. 5. McSweeney PA, Niederwieser D, Shizuru JA, et al. Hematopoietic cell transplantation in older patients with hematologic malignancies: re- placing high-dose cytotoxic therapy with graft-versus-tumor effects. Blood 2001; 97: 3390. 6. Spitzer TR, Delmonico F, Tolkoff-Rubin N, et al. Combined histocompati- bility leukocyte antigen-matched donor bone marrow and renal trans- plantation for multiple myeloma with end stage renal disease: the induction of allograft tolerance through mixed lymphohematopoietic chimerism. Transplantation 1999; 68(4): 480. 7. Kwong YL, Au WY, Liang RH. Acute myeloid leukemia after azathioprine treatment for autoimmune diseases: association with -7/7q. Cancer Genet Cytogenet 1998; 104(2): 94. 8. Germing U, Gattermann N, Strupp C, et al. Validation of the WHO proposal for a new classification of primary myelodysplastic syn- dromes: a retrospective analysis of 1600 patients. Leuk Res 2000; 24: 983. 9. Bolan CD, Leitman SF, Griffith LM, et al. Delayed donor red cell chimer- ism and pure red cell aplasia following major ABO-incompatible non- myeloablative hematopoietic stem cell transplantation. Blood 2001; 98: 1687. 10. Veelken H, Wa ¨ sch R, Behringer D, et al. Pure red cell aplasia after allogeneic stem cell transplantation with reduced conditioning. Bone Marrow Transplant 2000; 26(8): 911. RHABDOMYOLYSIS DUE TO RED YEAST RICE (Monascus purpureus) IN A RENAL TRANSPLANT RECIPIENT G. V. RAMESH PRASAD, 1,3 TIMOTHY WONG, 2 GALO MELITON, 1 AND SALMA BHALOO 2 Rhabdomyolysis is a known complication of hepatic 3-methylglutaryl coenzyme A reductase (HMG-CoA) inhibitor (statin) therapy for posttransplant hyperlip- idemia, and thus monitoring for this effect is indi- cated. We report a case of an herbal preparation-in- duced rhabdomyolysis in a stable renal-transplant recipient, attributed to the presence of red yeast rice (Monascus purpureus) within the mixture. The condi- tion resolved when consumption of the product ceased. Rice fermented with red yeast contains sev- eral types of mevinic acids, including monacolin K, which is identical to lovastatin. We postulate that the interaction of cyclosporine and these compounds through the cytochrome P450 system resulted in the adverse effect seen in this patient. Transplant recipi- ents must be cautioned against using herbal prepara- tions to lower their lipid levels to prevent such com- plications from occurring. Hyperlipidemia frequently occurs after solid organ trans- plantation (1) and often responds to therapy with hepatic 3-methylglutaryl coenzyme A reductase (HMG-CoA) inhibi- tors (statins) (2). The use of statins sometimes results in complications, including rhabdomyolysis (3, 4); thus, moni- toring for these adverse effects is indicated. We report the case of a renal transplant recipient who developed rhabdo- myolysis as the result of consuming an herbal preparation containing red yeast rice, which is known to possess statin- like activity (5). CASE REPORT A 28-year-old woman had received a live-donor allograft 6 years earlier for endstage renal disease attributed to hyper- tensive nephrosclerosis. There was good initial graft function with a baseline serum creatinine value of 150 mol/L (nor- mal 60 –120 mol/L). The significant problems that occurred posttransplant included hypertension, hyperlipidemia, and obesity. Her medications at the time of this study included Neoral cyclosporine (300 mg per day), azathioprine (50 mg per day), prednisone (7.5 mg per day), enalapril (40 mg per day), long-acting diltiazem (240 mg per day), and famotidine (40 mg per day). A routinely collected fasting lipid profile demonstrated a total cholesterol level of 6.03 mmol/L (target 5.2 mmol/L), high-density lipoprotein cholesterol level of 1.3 mmol/L (N 0.88 –2.28 mmol/L), low-density lipoprotein (LDL) cholesterol level of 4.2 mmol/L (target 2.5 mmol/L), and triglycerides level of 0.9mmol/L (target 2.0 mmol/L). Dietary intervention was attempted initially, but this failed to alter fasting lipid values. The patient was then offered statin therapy, but this was refused. Routine blood work performed 4 months later demon- strated a serum creatine phosphokinase (CPK) value of 1,050 U/L (N 0 –130 U/L). Serum transaminase, alkaline phospha- tase, and electrolyte levels were normal. The trough cyclo- sporine level was 255 ng/mL. Renal function was unchanged. The patient was summoned to the transplant clinic, where a repeat CPK value was 2,600 U/L. She denied any symptoms but upon further questioning admitted to consuming, for the previous 2 months, an unlicensed herbal preparation con- taining rice fermented with red yeast, beta-sitosterol, dan shen root (Salvia mitorriza), and garlic bulb (Allium sati- vum) in an attempt to lower her cholesterol “naturally.” She was instructed to cease consumption of the prepara- tion. The CPK value declined to 600 U/L in 2 weeks. She remained clinically well. 1 Division of Nephrology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada. 2 Department of Pharmacy, St. Michael’s Hospital, Toronto, On- tario, Canada. 3 Address correspondence to: Dr. G.V. Ramesh Prasad, Division of Nephrology, Department of Medicine, St. Michael’s Hospital, Uni- versity of Toronto, 61 Queen Street East, 9th Floor, Toronto, Ontario M5C 2T2 Canada. E-mail: prasadr@smh.toronto.on.ca. Received 12 May 2002. Accepted 30 May 2002. DOI: 10.1097/01.TP.0000031950.34040.79 TRANSPLANTATION 1200 Vol. 74, No. 8