Anemia in the Period Immediately Following Renal Transplantation

Influence of Pretransplant Factors on Posttransplant Anemia Recovery Rate in Primary Deceased Donor Kidney Transplant Recipients

OBJECTIVES

Our objective was to evaluate the influence of pretransplant risk factors on posttransplant anemia recovery.

MATERIALS AND METHODS

This single-center observational retrospective study included 80 deceased donor kidney transplant recipients who had been followed up to 16 months after kidney transplant. Time point of posttransplant anemia recovery was considered the time when hemoglobin of 11.0 g/dL was achieved and maintained for 3 consecutive monthly visits. We collected donor/transplant characteristics (age, sex, hypertension history, cause of death, donor kidney function, expanded criteria donor status, deceased donor score, HLA mismatch, and cold ischemia time) and recipient data (pretransplant hemoglobin, parathyroid hormone, kidney graft function, delayed graft function, acute rejection, infections, surgical bleeding, posttransplant parathyroid hormone, iron stores, and C-reactive protein and tacrolimus levels). We used univariate and multivariate Cox proportional hazards analyses and Kaplan-Meier plots to determine associations between variables and posttransplant anemia recovery rate. P < .05 was considered significant.

RESULTS

We identified 62 deceased donors (33 male; mean age 50 ± 15.1 years) and 80 kidney transplant recipients (52 male; mean age 47.0 ± 10.6 years). Mean pretransplant hemoglobin was 11.4 ± 1.5 g/dL. Donor age, deceased donor score, pretransplant parathyroid hormone, posttransplant transferrin saturation (all P < .05), and tacrolimus level (P < .01) were significantly related to posttransplant anemia recovery. Kaplan-Meier curve identified that recipients of deceased donors below 60 years old achieved hemoglobin of 11.0 g/dL more frequently and earlier than recipients of deceased donors above 60 years old (P < .05).

CONCLUSIONS

Deceased donor age, deceased donor score, pretransplant serum parathyroid hormone, posttransplant transferrin saturation, and tacrolimus level were significantly associated with posttransplant anemia recovery rate in deceased donor kidney transplant recipients. Anemia recovery was more frequent and earlier in recipients of deceased donors below 60 years than in recipients of donors 60 years old and above.

Blood disorders after kidney transplantation

Post transplant anemia (PTA) is a common issue in kidney transplant recipients. Most importantly it is associated with an impaired allograft function. Other important factors associated with PTA are immunosuppressive drugs (MPA, AZA and SRL), iron deficiency, infections (Parvo B19), older donor age, rejection episodes, an increased inflammatory state, and erythropoietin hyporesponsiveness. As there are no adequately powered RCTs in the kidney transplant population on anemia treatment with ESA, we have to rely on what we know from the large RCTs in the CKD population. The recently published KDIGO guidelines do not recommend treatment with ESA if Hb is >10 g/dl. Repletion of iron stores is emphasized. Post transplant leukopenia (PTL) and thrombocytopenia (PTT) are frequent complications especially in the first six months after kidney transplantation. Myelosuppression caused by immunosuppressive agents (MPA, AZA, SRL, rATG), antimicrobial drugs (VGCV), and CMV infection is the predominant cause. There are no widely accepted guidelines on treatment strategies, but most often dose reduction or discontinuation of causative medication is done. Most clinicians tend to decrease MPA dose, but this is eventually associated with an increase in acute rejection episodes. VGCV dose reduction (preemptive treatment instead of CMV prophylaxis) may be a successful strategy. In severe cases G-CSF treatment is an important management option and seems to be safe.

Risk factors of post renal transplant anaemia among Sudanese patients, a study in three renal transplant centres

Background

There is a relative lack of recent information about late post kidney transplantation anaemia (PTA), especially in the developing countries; data are scarce about the prevalence and risk factors of PTA. Sudan was a leading country in Africa and Arab world in kidney transplantation. The first kidney transplantation in Sudan was in 1973.

Methods

This is a cross-sectional hospital analytic study enrolling all kidney transplanted recipients following in the transplant referral clinics at Ahmed Gassim, Selma and Ibn Sina Hospitals, Khartoum/Sudan, in the period from 1/8/2010 to 1/9/2010, clinical and laboratory data were obtained from 114 patients, anaemia was defined as Hb levels of < 13 g/dl for male patients and < 12 g/dl for female patients, exclusion criteria were pregnancy, below 18 years old patients, multiple organ transplantation, and patients with less than one year from the transplantation.

Results

The study showed that 39.5% of the patients were anaemic. Univariate analysis showed that late PTA is significantly associated with not using Erythropoietin (EPO) in the pre-transplant period (p = < 0.001), history of rejection (p = 0.003), longer time from transplantation (p = 0.015), and eGFR (p < 0.0001). Multivariate analysis showed that eGFR (p = < 0.001) and not use of EPO in the pre transplant period (p < 0.001) are strong predictors of PTA. The use of Angiotensin converting enzyme inhibitors/Angiotensin receptors blockers (ACEI/ARB), immunosuppressive treatments, presence or absence of co-morbidities, donor type and donor age are not significantly associated with late PTA.

Conclusion

The study concluded that late PTA is common and under recognized. Risk factors for late PTA include renal dysfunction, history of rejection, longer duration of transplantation and not using EPO in the pre-transplant period. Renal dysfunction and not using EPO in the pre-transplant period are major predictors of late PTA.

Risk factors for immediate anemia in renal transplant recipients: a single-center experience

BACKGROUND

Although endogenous erythropoietin secretion returns via the renal allograft a few hours following successful engraftment, anemia is a common early or late complication. In addition, anemia is a risk factor for ischemic heart disease and graft loss. We sought to determine risk factors for and the prevalence of severe anemia immediately posttransplantation (PTA).

METHODS

This cross-sectional retrospective study performed between 2006 and 2009 enrolled 864 adult subjects of mean age 40.7±13.8 (range=6-75) years. On the basis of The World Health Organization criteria, a hemoglobin (Hb) level less than 11 g/dL for men and less than 10 g/dL for women was defined as severe anemia.

RESULTS

Severe anemia occurred frequently (62.7%) among these patients whose most common underlying disease was hypertension 311 (58.2%). Their mean Hb level was 9.9±1.8 g/dL at the time of hospital discharge, namely, almost 2 weeks after transplantation. More than 90% (n=778) of subjects received a kidney from a living donor. Immediate severe anemia associated with delayed graft function (DGF; P=.01), antithymocyte globulin (ATG)/antilymphocyte globulin (ALG) administration (P=.000), acute rejection (P=.000), recipient gender (P=.000), cold ischemic time (P=.01), pretransplant Hb (P=.000), posttransplant creatinine (P=.001), and acute rejection episodes (P=.000). Upon logistic regression analysis donor age (P=.04, confidence interval [CI]=0.7-0.9), recipient female gender (P=.009, CI=0.08-0.7), and ATG/ALG use (P=.009, CI=1.7-43.4) showed significant effects to cause severe PTA.

CONCLUSION

Immediate anemia after renal transplantation is a consequence of poor renal function. In addition, ATG/ALG use and DGF can induce severe PTA, which may play roles in ischemic heart disease and graft loss.

Prevalence and predictive factors of anemia after renal transplantation: a Moroccan report. Transplant Proc. 2010;42:3542-3549. [PMID: 21094812 DOI: 10.1016/j.transproceed.2010.07.092]

OBJECTIVE

Anemia, a common multifactorial problem in kidney transplant recipients, represents an important cardiovascular risk factor. The purpose of this study was to assess anemia prevalence after kidney transplantation, the main factors involved in its occurrence, its cardiovascular consequences, and its impact on patient survival and graft function.

METHODS

This retrospective study evaluated 69 patients undergoing renal transplantation between January 1998 and September 2008 with ≥1 year of follow-up. For all of the patients, we recorded hemoglobin concentrations before and at 1, 3, 6, 12, 36, and 60 months after transplantation. Anemia was defined as recommended by the American Society of Transplantation: hemoglobin level <12 g/dL in women and <13 g/dL in men. To determine the factors involved in anemia occurrence, we compared 2 groups of patients, with versus without anemia, at various times after renal transplantation.

RESULTS

This study showed a high prevalence of anemia in the early posttransplantation period of 82.7% and 42% of kidney transplantation patients at 1 month and 6 months, respectively. It was mainly related to a low pretransplant hemoglobin level. The prevalence declined to 37.7% at 1 year. Renal graft dysfunction was the most important factor in the occurrence of late post-renal transplantation anemia. The presence of anemia increased the risk of renal graft functional deterioration by a factor of 2.9. The decreased prevalence at 1 year after transplantation was significantly associated with a reduction in left ventricular hypertrophy.

CONCLUSION

The management of anemia is essential to improve renal graft survival, reduce cardiovascular morbidity, and ensure a better quality of life for renal transplant recipients.

Hematologic abnormalities following renal transplantation

Recipients of renal allografts are surviving longer and, consequently, may experience a variety of complications related not only to the transplanted kidney, but also to the hematopoietic system. Common hematologic complications in the renal transplant patient include abnormalities of one cell line, such as post-transplantation erythrocytosis or anemia, that are often treatable with simple measures. Conversely, pathologies involving the leukocyte and platelet population often exist in the context of pancytopenia, which may be a manifestation of systemic infection (e.g., cytomegalovirus, human herpesvirus 8) or malignancy (post-transplantation lymphoproliferative disorders). Uncommon, but life-threatening, processes complicating renal transplantation include hepatosplenic gammadelta T-cell lymphoma and viral-induced hemophagocytic syndrome, both of which are associated with severe pancytopenia and, often, death. Since this patient population is often managed in a multidisciplinary fashion by nephrologists, infection specialists, transplant surgeons, hematologists, and internal medicine physicians, a succinct review of this topic is warranted.