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Wilder IW, Reskallah A, Pivalizza CM, Bynon JS, Pivalizza EG. Refractory thrombocytopenia during liver transplantation requiring splenectomy. Proc AMIA Symp 2022; 36:96-98. [PMID: 36578624 PMCID: PMC9762830 DOI: 10.1080/08998280.2022.2126928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Although thrombocytopenia is common in end-stage liver disease, severe, refractory thrombocytopenia during liver transplantation is rare, and if immune based, usually presents months or years later. This case describes an adult woman in whom preoperative evaluation had not determined an immune-related cause of thrombocytopenia. Clot strength was dramatically impaired as measured by thrombelastography during the transplant. Following a lack of response to repeat platelet transfusions, splenectomy was performed after graft reperfusion with rapid temporal restoration of clot strength. This case shows a severe manifestation of perioperative thrombocytopenia during liver transplantation and clinically guided management when measured clot strength is too low for accurate determination.
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Affiliation(s)
| | - Alexander Reskallah
- Department of Anesthesiology, Critical Care and Pain Medicine, MD Anderson Cancer Center, Houston, Texas
| | | | - John S. Bynon
- Department of Transplant Surgery, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Evan G. Pivalizza
- Department of Anesthesiology, McGovern Medical School at UTHealth Houston, Houston, Texas,Corresponding author: Evan G. Pivalizza, MBChB, Department of Anesthesiology, McGovern Medical School at UTHealth Houston, 6431 Fannin St., MSB 5.020, Houston, TX77030 (e-mail: )
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2
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Thomas W, Foukaneli T, Cosgrove J, Massey D, Woodward J, Middleton S, Besser M, Russell N, Amin I, Butler A, Sharkey L. Transplant-associated thrombotic microangiopathy and immune haematological complications following intestine-containing organ transplantation: experience from over 100 consecutive cases. Br J Haematol 2021; 193:961-970. [PMID: 33954989 DOI: 10.1111/bjh.17430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/02/2021] [Accepted: 03/02/2021] [Indexed: 01/19/2023]
Abstract
Descriptions of passenger lymphocyte syndrome (PLS), immune cytopenias and transplant-associated thrombotic microangiopathy (TA-TMA) after intestine-containing transplants remain scarce. We describe our centre's experience of these complications from 2007 to 2019. Ninety-six patients received 103 transplants. PLS occurred in 9 (9%) patients (median 12 days post-transplant); all due to ABO antibodies. There were 31 minor ABO mismatch transplants. No patient required change in immunosuppression. Immune cytopenias (excluding PLS) occurred in six patients at an incidence of 1·7/100 patient years; three immune haemolysis, one immune thrombocytopenia, one acquired Glanzmann's and one immune neutropenia; 50% occurred with other cytopenias. All cases eventually responded to treatment, with a median of four treatments (range 1-8) and 5/6 were treated with rituximab. One patient with immune haemolysis required bortezomib. Complications were common in patients with immune cytopenias; 4/6 with infection needing intravenous antibiotics and 3/6 with venous thromboembolism. In 3/6 cases, a secondary cause for the immune cytopenia was evident. Switching from tacrolimus to ciclosporin was not necessary. There were five cases of transplant-associated thrombotic microangiopathy (TA-TMA; 1·5/100 patient years) requiring calcineurin inhibitor withdrawal; two cases associated with acute rejection. Two cases were managed with plasma exchange, one with plasma infusions and one with eculizumab. Further research in this patient group is required.
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Affiliation(s)
- Will Thomas
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Theodora Foukaneli
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,NHS Blood and Transplant, Cambridge, UK
| | - Joyce Cosgrove
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Dunecan Massey
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jeremy Woodward
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stephen Middleton
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Martin Besser
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Neil Russell
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Irum Amin
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew Butler
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Lisa Sharkey
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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3
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Bull T, Jolley R, Martin-Cabrera P, Thomas W. Autoimmune pancytopenia occurring late after simultaneous pancreas and kidney transplantation. BMJ Case Rep 2020; 13:13/9/e235851. [PMID: 32900732 DOI: 10.1136/bcr-2020-235851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
A 35-year-old woman presented with a widespread petechial rash and pancytopenia. She underwent simultaneous pancreas and kidney transplantation for type 1 diabetes 8 years previously followed by a renal transplant 1 year prior to presentation, and was taking tacrolimus as long-term immunosuppression. The full blood count showed haemoglobin 97 g/L, platelet count 2×109/L and neutrophil count 0.22×109/L. Peripheral blood film examination confirmed genuine thrombocytopenia in the absence of any haemolytic or malignant features. Serological testing identified autoantibodies against all three blood lineages, consistent with a diagnosis of autoimmune pancytopenia. Treatment with steroids, intravenous immunoglobulins, romiplostim and mycophenolate mofetil achieved only fleeting remissions. Blood counts eventually normalised following the administration of rituximab and a change from tacrolimus to ciclosporin immunosuppression. Cytopenias are a well-recognised complication of post-transplantation care but we believe this to be the first reported case of autoimmune pancytopenia following solid organ transplantation. In this case report, we discuss the approach to investigation of haematological abnormalities post-transplant and the rationale for, and outcome of, the management of this rare case.
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Affiliation(s)
- Tom Bull
- Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ruth Jolley
- Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - William Thomas
- Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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4
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Dermatological Disorders following Liver Transplantation: An Update. Can J Gastroenterol Hepatol 2019; 2019:9780952. [PMID: 31058114 PMCID: PMC6463607 DOI: 10.1155/2019/9780952] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 02/24/2019] [Accepted: 03/11/2019] [Indexed: 02/08/2023] Open
Abstract
Patients undergoing liver transplantation (LT) are at a high risk of dermatological complications compared to the general population as a result of long-term use of immunosuppressant. However, the risk is not as high as other solid organ transplantations (SOT), particularly for skin cancer. The liver is considered as an immune privileged organ since it has a low prevalence of humoral rejection in contrast to other SOT, and thus, LT requires a minimal amount of immunosuppressants compared to other SOT recipients. However, because of the large volume of the liver, patients with LT have higher donor lymphocytes that sometimes may trigger graft-versus-host-disease, yet it is rare. On the other hand, the vast majority of the nonspecific dermatological lesions linked with cirrhosis improve after removal of diseased liver or due to the immunosuppressant used after LT. Nevertheless, dermatological infections related to bacteria, viruses, and fungus after LT are not uncommon. Additionally, the incidence of IgE-mediated food allergies develops in 12.2% of LT patients and may present as life-threatening conditions such as urticaria and/or angioedema and hypersensitivity. Moreover, skin malignancies after LT are a matter of concern. Thus, posttransplant dermatological care should be provided to all LT patients for any suspicious dermatological lesions. Our goal is to give an outline of the dermatological manifestation associated with LT for the clinicians by collecting the published data from all archived case reports.
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5
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Grunebaum E, Avitzur Y. Liver-associated immune abnormalities. Autoimmun Rev 2018; 18:15-20. [PMID: 30408587 DOI: 10.1016/j.autrev.2018.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 06/30/2018] [Indexed: 01/19/2023]
Abstract
In recent years, the cross talk between the liver and the immune system is being uncovered, in part by studying liver involvement in primary immune deficiencies (PID) and in part by investigating the alterations of the immune system following orthotopic liver transplantation (OLT). Here we review some of the reciprocal interactions between the liver and the immune system. Patients with PID, particularly those involving inherited defects in T and B cells or innate immunity are prone to infections and inflammatory responses that often involve the liver. Omenn's syndrome, familial hemophagocytic lymphohistiocytosis, AIRE, FOXP3 and CD25 deficiencies, common variable immunodeficiency, CD40 ligand deficiency, chronic granulomatous disease and autoimmune lymphoproliferative syndrome are some of the notable PID associated with typical hepatobiliary abnormalities. Knowledge gained from studying these PID together with laboratory and histological evaluations can assist in managing PID-associated liver dysfunction. The liver itself also has important effects on the immune system, as evident from the growing experience with patients surviving OLT. Up to 40% of pediatric patients who receive OLT suffer from post transplantation allergy, autoimmunity, and immune-mediated disorders (PTAA). PTAA is more common after liver and heart transplantations than kidney transplantations. Potential contributing factors for the increased frequency of PTAA after OLT include the age of the patients, the prolonged use of tacrolimus and the reduced regulatory immune function with a shift towards a TH2 immune response. Better understanding of the mechanisms leading to the development of PTAA after OLT will also improve the management of these conditions.
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Affiliation(s)
- Eyal Grunebaum
- Division of Immunology and Allergy, Department of Pediatrics, Hospital for Sick Children, Toronto, Canada; The Food Allergy and Anaphylaxis Program, Hospital for Sick Children, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
| | - Yaron Avitzur
- University of Toronto, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
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6
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Hoveidaei AH, Soufi H, Dehghani SM, Imanieh MH. Successful Treatment of Idiopathic Thrombocytopenic Purpura After Liver Transplant: A Case Report. EXP CLIN TRANSPLANT 2018; 18:649-652. [PMID: 30066626 DOI: 10.6002/ect.2018.0083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Idiopathic thrombocytopenic purpura, a common acquired bleeding disorder in pediatric patients, is an autoimmune disorder characterized by a low platelet count. Organ transplant can transfer such diseases, but the occurrence of idiopathic thrombocytopenic purpura after liver transplant is rare. Here, we report a 17-month-old girl who was diagnosed with idiopathic thrombocytopenic purpura and who had a history of liver transplant 11 months earlier. Treatment of cytomegalovirus and Epstein-Barr virus infection led to a successful outcome.
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Affiliation(s)
- Amir Human Hoveidaei
- >From the Student Research Committee, Nemazee Hospital; Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hoda Soufi
- >From the Department of Pediatric Gastroenterology, Gastroenterohepatology Research Center of Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Mohsen Dehghani
- >From the Gastroenterohepatology Research Center, Nemazee Hospital; Shiraz University of Medical Science, Shiraz, Iran
| | - Mohammad Hadi Imanieh
- >From the Transplant Research Center, Nemazee Hospital; Shiraz University of Medical Science, Shiraz, Iran
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7
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Takahashi K, Nagai S, Safwan M, Liang C, Ohkohchi N. Thrombocytopenia after liver transplantation: Should we care? World J Gastroenterol 2018; 24:1386-1397. [PMID: 29632420 PMCID: PMC5889819 DOI: 10.3748/wjg.v24.i13.1386] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/06/2018] [Accepted: 03/18/2018] [Indexed: 02/06/2023] Open
Abstract
Transient thrombocytopenia is a common phenomenon after liver transplantation. After liver transplantation (LT), platelet count decreases and reaches a nadir on postoperative days 3-5, with an average reduction in platelet counts of 60%; platelet count recovers to preoperative levels approximately two weeks after LT. The putative mechanisms include haemodilution, decreased platelet production, increased sequestration, medications, infections, thrombosis, or combination of these processes. However, the precise mechanisms remain unclear. The role of platelets in liver transplantation has been highlighted in recent years, and particular attention has been given to their effects beyond hemostasis and thrombosis. Previous studies have demonstrated that perioperative thrombocytopenia causes poor graft regeneration, increases the incidence of postoperative morbidity, and deteriorates the graft and decreases patient survival in both the short and long term after liver transplantation. Platelet therapies to increase perioperative platelet counts, such as thrombopoietin, thrombopoietin receptor agonist, platelet transfusion, splenectomy, and intravenous immunoglobulin treatment might have a potential for improving graft survival, however clinical trials are lacking. Further studies are warranted to detect direct evidence on whether thrombocytopenia is the cause or result of poor-graft function and postoperative complications, and to determine who needs platelet therapies in order to prevent postoperative complications and thus improve post-transplant outcomes.
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Affiliation(s)
- Kazuhiro Takahashi
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, University of Tsukuba, Tsukuba, Ibaraki 3058575, Japan
| | - Shunji Nagai
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, ML 48202, United States
| | - Mohamed Safwan
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, ML 48202, United States
| | - Chen Liang
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, University of Tsukuba, Tsukuba, Ibaraki 3058575, Japan
| | - Nobuhiro Ohkohchi
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, University of Tsukuba, Tsukuba, Ibaraki 3058575, Japan
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8
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Immune thrombocytopenic purpura presenting in a patient after renal transplant for diabetic nephropathy. BMC Nephrol 2018; 19:69. [PMID: 29554892 PMCID: PMC5859404 DOI: 10.1186/s12882-018-0868-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 03/08/2018] [Indexed: 11/10/2022] Open
Abstract
Background Immune thrombocytopenic purpura (ITP) is primarily characterized by immune-mediated destruction of platelets in circulation. Major treatment options range from careful observation, steroids, immunosuppressive medications, immunoglobulins to splenectomy. Interestingly and rarely, ITP has also been reported after solid organ transplantation in patients receiving immunosuppressive medications. While the incidence of new onset ITP after solid organ transplant is comparatively well documented, new onset ITP after renal transplant has only been reported in two patients. Both these patients underwent renal transplant for underlying Immunoglobulin-A (IgA) nephropathy and were treated effectively with steroids. We present successful management of the first reported case of new-onset ITP presenting after renal transplant in a patient with underlying diabetic nephropathy. The case report discusses the potential management strategies in such a novel scenario aiming simultaneously for a well-functioning renal graft, adequate hemostasis, minimum therapy- related morbidity and least cost implications for the patient. Case Presentation A 43-year-old male with hypertension and diabetes mellitus (DM), complicated by nephropathy and retinopathy, underwent pre-emptive living related renal transplant by donation from his 33-year-old wife. His immediate post-transplant period was unremarkable. Six months after the transplant, he presented with isolated thrombocytopenia. An extensive workup revealed no clinical or laboratory evidence of unusual substance intake, infection, hemolysis, microangiopathy, autoimmune disease or hematological malignancy. Eight months after the transplant, while the patient was maintained on steroids, cellcept and tacrolimus, his platelet count dipped to 13,000/microL and he had an episode of mild epistaxis. He was administered steroids in line with the adult ITP management protocol. Steroids were well tolerated, and platelet counts showed a good response to therapy. Steroids were then successfully tapered over the next ten weeks with steady and acceptable platelet counts and graft function. Conclusions The case report discusses the diagnostic considerations and successful management of new-onset post-renal transplant ITP. It also highlights the various therapeutic options available in the medical armamentarium including shuffling of immunosuppressive drugs, rituximab, thrombopoietin receptor agonists (TPO’s) and splenectomy for their potential use in complicated scenarios like relapsing, or steroid-refractory post renal transplant ITP.
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9
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Hematologic Manifestations of Childhood Illness. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00152-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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10
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Patel S, Levin-Epstein R, Kobashigawa J. Piperacillin-induced Thrombocytopenia in a Dual Heart and Kidney Transplant Patient: A Case Report. Transplant Proc 2017; 49:1672-1674. [DOI: 10.1016/j.transproceed.2017.02.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 02/07/2017] [Indexed: 01/16/2023]
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11
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Tan A, Florman SS, Schiano TD. Genetic, hematological, and immunological disorders transmissible with liver transplantation. Liver Transpl 2017; 23:663-678. [PMID: 28240807 DOI: 10.1002/lt.24755] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 02/14/2017] [Indexed: 12/08/2022]
Abstract
It is well recognized that solid organ transplantation can transmit bacterial infection and chronic viral hepatitis as well as certain cancers. As indications for liver transplantation (LT) have expanded, it has been used to treat and even cure certain genetic cholestatic disorders, urea cycle defects, and coagulation abnormalities; many of these conditions are potentially transmissible with LT as well. It is important for clinicians and transplant patients to be aware of these potentially transmissible conditions as unexplained post-LT complications can sometimes be related to donor transmission of disease and thus should prompt a thorough exploration of the donor allograft history. Herein, we will review the reported genetic, metabolic, hematologic, and immunological disorders that are transmissible with LT and describe clinical scenarios in which these cases have occurred, such as in inadvertent or recognized transplantation of a diseased organ, domino transplantation, and with living related liver donation. Liver Transplantation 23 663-678 2017 AASLD.
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Affiliation(s)
- Amy Tan
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sander S Florman
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
| | - Thomas D Schiano
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.,Division of Liver Diseases, Mount Sinai Medical Center, New York, NY.,Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
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12
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Trotter PB, Robb M, Summers D, Watson CJE, Clatworthy M, Bradley JA, Hill QA, Neuberger J. Donors With Immune Thrombocytopenia: Do They Pose a Risk to Transplant Recipients? Am J Transplant 2017; 17:796-802. [PMID: 27935215 DOI: 10.1111/ajt.14105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 09/26/2016] [Accepted: 10/21/2016] [Indexed: 01/25/2023]
Abstract
Transplant-mediated alloimmune thrombocytopenia (TMAT) from donors with immune thrombocytopenia (ITP) can result in significant bleeding complications in the recipient. The risk to a recipient of TMAT if they receive an organ from a donor with ITP is unknown. The outcomes of recipients of organs from deceased donors with ITP recorded in the UK Transplant Registry between 2000 and 2015 were reviewed. Twenty-one deceased organ donors had a predonation diagnosis of ITP. These donors were significantly more likely to have died from intracranial hemorrhage than were all other deceased organ donors (85% vs. 57%, p < 0.001). Organs from donors with ITP resulted in 49 organ transplants (31 kidney, 14 liver, four heart), with only one case of TMAT, which occurred in a liver transplant recipient and resulted in death from bleeding complications 18 days posttransplantation. The recipient of a kidney from the same organ donor was not affected. Unadjusted 5-year patient and graft survival was significantly worse for liver transplant recipients from donors with ITP compared with liver transplant recipients from donors without ITP (64% vs. 85%, p = 0.012). Organs from donors with ITP may be considered for transplantation, but livers should be used with caution.
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Affiliation(s)
- P B Trotter
- National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK.,Organ Donation and Transplantation Directorate, NHS Blood and Transplant, Bristol, UK
| | - M Robb
- Organ Donation and Transplantation Directorate, NHS Blood and Transplant, Bristol, UK
| | - D Summers
- National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK.,Organ Donation and Transplantation Directorate, NHS Blood and Transplant, Bristol, UK
| | - C J E Watson
- National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK
| | - M Clatworthy
- National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK
| | - J A Bradley
- National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK
| | - Q A Hill
- Department of Haematology, St James's University Hospital, Leeds, UK
| | - J Neuberger
- Organ Donation and Transplantation Directorate, NHS Blood and Transplant, Bristol, UK
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13
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ARAI KEISUKE, KURAMITSU KAORI, FUKUMOTO TAKUMI, KIDO MASAHIRO, TAKEBE ATSUSHI, TANAKA MOTOFUMI, KINOSHITA HISOKA, AJIKI TETSUO, TOYAMA HIROCHIKA, ASARI SADAKI, GOTO TADAHIRO, KU YONSON. A Case Report of Drug-Induced Thrombocytopenia after Living Donor Liver Transplantation. THE KOBE JOURNAL OF MEDICAL SCIENCES 2016; 62:E9-E12. [PMID: 27492209 PMCID: PMC5433727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 01/26/2016] [Indexed: 06/06/2023]
Abstract
There are few descriptions of severe thrombocytopenia during the early postoperative period after liver transplantation, and these have not been fully documented in the literature. Here, we report a case of drug-induced thrombocytopenia requiring transfusion of blood products after living donor liver transplantation. We determined that this was not caused by the interferon-free anti-viral therapy but by tacrolimus A 61-year-old woman with hepatitis C-related cirrhosis and hepatorenal syndrome underwent living donor liver transplantation using a left lobe graft from her son. After transplantation, immunosuppression consisted of tacrolimus and steroid. Seven weeks after transplantation, interferon-free therapy with daclatasvir and asunaprevir was started. Thirteen days thereafter, hepatitis C virus tested negative. However, the platelet count had begun to gradually decrease just before starting anti-viral therapy. Daclatasvir and asunaprevir were stopped because this was suspected to be a side-effect of these drugs, but the patient nonetheless went on to develop severe thrombocytopenia (platelet count 17,000/μL), which needed transfusions. Now suspecting tacrolimus as the inducer of this side effect, we changed to cyclosporin, after which the platelet count gradually recovered. Viral markers were still not detectable up to 2 months after discontinuation of the antiviral drugs. We conclude that when severe thrombocytopenia occurs, possible drug-induced thrombocytopenia as well as other disorders must be investigated.
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Affiliation(s)
- KEISUKE ARAI
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan
| | - KAORI KURAMITSU
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan
| | - TAKUMI FUKUMOTO
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan
| | - MASAHIRO KIDO
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan
| | - ATSUSHI TAKEBE
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan
| | - MOTOFUMI TANAKA
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan
| | - HISOKA KINOSHITA
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan
| | - TETSUO AJIKI
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan
| | - HIROCHIKA TOYAMA
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan
| | - SADAKI ASARI
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan
| | - TADAHIRO GOTO
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan
| | - YONSON KU
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan
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14
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Gao W, Song JL, Yang J, Yang JY, Yan LN. Successful Treatment of Severe Immune Thrombocytopenia After Orthotopic Liver Transplant. EXP CLIN TRANSPLANT 2016; 16:103-106. [PMID: 27001430 DOI: 10.6002/ect.2015.0219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Here, we report a case of severe immune thrombocytopenia that occurred after orthotopic liver transplant. On day 16 after transplant, the patient was readmitted to our hospital with a platelet count of 0 cells/mL, with the count remaining at a low level of 1000 to 10 000 cells/mL for 46 days. A diagnosis was made, after exclusion of other causes, of thrombocytopenia. Platelet blood transfusion and high-dose prednisone (1mg/kg/d) combined with intravenous immunoglobulin (0.5g/kg/d) were administered with no improvement. After additional treatments, which included altered use of immunosuppressive agents, changing adefovir to lamivudine and continuous steroid therapy, the patient was discharged with a platelet count of 55 000 cells/mL. Both liver and renal functions generally stayed well during hospitalization. The patient was discharged uneventfully and achieved remission during 10-month follow-up after discharge.
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Affiliation(s)
- Wei Gao
- From the Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
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15
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Schoettler M, Elisofon SA, Kim HB, Blume ED, Rodig N, Boyer D, Neufeld EJ, Grace RF. Treatment and outcomes of immune cytopenias following solid organ transplant in children. Pediatr Blood Cancer 2015; 62:214-218. [PMID: 25308853 PMCID: PMC4394012 DOI: 10.1002/pbc.25215] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 07/10/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Immune cytopenias are a recognized life-threatening complication following pediatric solid organ transplants (SOT), but treatment responses and overall outcome are not well described. The aim of this study was to evaluate the demographic characteristics, response to treatments, and outcomes of a cohort of patients who developed immune cytopenias following SOT. PROCEDURE In this single center retrospective review, patients with immune cytopenias after SOT were identified by electronic medical record (EMR) search and transplant databases from 1995-2012. RESULTS Of 764 SOT patients, 19 (2.4%) developed immune cytopenias. Incidence varied widely by transplant type from 1.2% (renal) to 23.5% (multivisceral). Autoimmune hemolytic anemia (AIHA) was the most common immune cytopenia. Overall median time from transplant to immune cytopenia was 8 m and varied by transplant type from 3 m (liver) to 74 m (heart). Standard therapies for immune cytopenias were often used and ineffective. The most effective therapy for the immune cytopenia was changing immunosuppression from tacrolimus to another agent. Three of 19 patients died; none directly attributed to the immune cytopenia. CONCLUSIONS Immune cytopenias are not rare after SOT, and patients usually do not respond well to traditional first line therapies. Provided that the risk of organ rejection is otherwise manageable, temporary cessation of tacrolimus could be more widely explored in this challenging clinical context. Pediatr Blood Cancer 2015;62:214-218. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
- Michelle Schoettler
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA
| | - Scott A Elisofon
- The Division of Gastroenterology, Boston Children's Hospital, Boston, MA
| | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | | | - Nancy Rodig
- Division of Nephrology, Boston Children's Hospital, Boston, MA
| | - Debra Boyer
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA
| | - Ellis J Neufeld
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA
| | - Rachael F Grace
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA
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16
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Kaestner F, Kutsogiannis DJ. Successful kidney and liver transplantation from a donor with immune thrombocytopenia. Transplant Proc 2014; 45:2838-40. [PMID: 24034062 DOI: 10.1016/j.transproceed.2013.02.136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 01/11/2013] [Accepted: 02/16/2013] [Indexed: 12/26/2022]
Abstract
Antibodies directed against platelet-surface antigen cause immune thrombocytopenia. Transplantation from a donor with immune thrombocytopenia has rarely been reported in the literature and never with a platelet count of 1 × 10(9)/L. We report one liver transplant recipient and one kidney transplant recipient who received organs from a donor with immune thrombocytopenia dying from intracranial hemorrhage. The kidney recipient showed no evidence of thrombocytopenia after transplantation. However, in the liver recipient, the platelet count nadired at 4 × 10(9)/L and normalized within 3 months. Transplantation of a liver from a donor suffering from immune thrombocytopenia must be considered with great caution. Other organs are suitable for transplantation; however, recipients of these organs must be followed carefully for evidence of immune thrombocytopenia and treatment offered accordingly.
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Affiliation(s)
- F Kaestner
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, The University of Alberta, Edmonton, Alberta, Canada
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17
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Ünlüsoy Aksu A, Eğritaş Gürkan Ö, Sarı S, Yenicesu İ, Dalgıç B. Immune thrombocytopenic purpura in a liver transplant patient. EXP CLIN TRANSPLANT 2014; 12 Suppl 1:175-177. [PMID: 24635822 DOI: 10.6002/ect.25liver.p49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
Thrombocytopenia is common during the early posttransplant period. Most cases are mild and recover in 1 month. Occasionally, severe thrombocytopenia may occur in the late posttransplant period. We report a 10-year-old boy with severe thrombocytopenia 3.5 years after liver transplant. We exclude secondary causes of thrombocytopenia. Bone marrow aspiration findings and treatment response were suggestive for immune thrombocytopenic purpura. The patient was treated with intravenous immunoglobulin at thrombocytopenia periods successfully. We continued tacrolimus, but preferred a reduced dose. In conclusion, immune thrombocytopenic purpura should be borne in mind as a reason of late onset, severe thrombocytopenia after liver transplant.
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Affiliation(s)
- Aysel Ünlüsoy Aksu
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Gazi University, Ankara, Turkey
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18
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Piano S, Gatta A, Angeli P. Immune thrombocytopenic purpura and Kaposi's sarcoma in a liver transplant recipient. Transpl Int 2012; 25:e50-2. [PMID: 22417011 DOI: 10.1111/j.1432-2277.2011.01424.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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19
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Miloh T, Arnon R, Roman E, Hurlet A, Kerkar N, Wistinghausen B. Autoimmune hemolytic anemia and idiopathic thrombocytopenic purpura in pediatric solid organ transplant recipients, report of five cases and review of the literature. Pediatr Transplant 2011; 15:870-8. [PMID: 22112003 DOI: 10.1111/j.1399-3046.2011.01596.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cytopenias are common among pediatric SOT; however, autoimmune cytopenias are infrequently reported. We report five cases of autoimmune cytopenias in pediatric LT patients: two with isolated IgG-mediated AIHA, two with ITP, and one with Evans syndrome (ITP and AIHA). All patients were maintained on tacrolimus as immunosuppression. Viral illness commonly preceded the autoimmune cytopenias. All patients responded well to medical therapy (steroids, intravenous immunoglobulin, and rituximab) and lowering tacrolimus serum level. Prognosis appears to be worse when more than one cell line (e.g., Evans syndrome) is affected, and/or there is no preceding viral illness. A critical literature review of autoimmune cytopenias in children following SOT is conducted. Autoimmune cytopenias are a rarely reported complication of pediatric SOT, but clinicians taking care of pediatric transplant recipients need to be aware of this complication.
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Affiliation(s)
- Tamir Miloh
- Department of Gastroenterology, Phoenix Children's Hospital, Phoenix, AZ 85016, USA.
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20
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Burlak C, Paris LL, Chihara RK, Sidner RA, Reyes LM, Downey SM, Tector AJ. The fate of human platelets perfused through the pig liver: implications for xenotransplantation. Xenotransplantation 2011; 17:350-61. [PMID: 20955292 DOI: 10.1111/j.1399-3089.2010.00605.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Pig liver xenotransplantation could offset the shortage of livers available for orthotopic liver transplantation. Studies in pig and baboon liver xenografts revealed the main obstacle to be a lethal thrombocytopenia that occurred within minutes to hours of transplantation. METHODS We have created a model of xenotransplantation-induced thrombocytopenia using ex vivo pig liver perfusion with human platelets. Thrombocytopenia was examined using fluorescently labeled platelets during the ex vivo perfusion and coculture with primary liver sinusoidal endothelial cells (LSEC). RESULTS Ex vivo liver perfusion revealed that 93% of human platelets were removed from circulation after 15 min. Endothelial cells and platelets were not activated based on tissue factor release into the perfusate. Biopsies from the ex vivo perfusion at 15 and 30 min and in vitro analysis indicated that human platelets are phagocytosed by pig LSEC and degraded in phagosomes. Sixty to 120 min after the addition of platelets to the ex vivo perfusion system, we observed platelet fragments and degraded platelets in hepatocytes. Platelet phagocytosis was not mediated by opsonization as Fc blocking had no effect on platelet phagocytosis. In vitro uptake of human platelets by primary LSEC cultures peaked at 15 min followed by a greater than 55% decrease in platelet fluorescence after 3 h. Primary pig LSEC phagosomes containing human platelets were colocalized with lysosomes positive for lysosome-associated membrane protein-1 (LAMP1), indicating the formation of mature phagosomes within pig LSEC. CONCLUSIONS Our observation of pig LSEC phagocytosis of human platelets describes a novel mechanism of large-particle uptake in the liver. The creation of a model system to study xenotransplantation-induced thrombocytopenia makes possible the investigation into mechanisms that mediate platelet loss.
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Affiliation(s)
- Christopher Burlak
- Department of Surgery, Clarian Transplant Institute, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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21
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Li L, Lv J, Xiao M, Luo XL, Zheng JF, Han DK. Clinical features of 27 cases with interferon alpha- induced severe thrombocytopenia. Shijie Huaren Xiaohua Zazhi 2009; 17:1147-1151. [DOI: 10.11569/wcjd.v17.i11.1147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze clinical features of interferon alpha-induced severe thrombocytopenia.
METHODS: Twenty six cases with interferon alpha-induced severe thrombocytopenic purpu-ra were collected from Medline and CNKI and another case from our clinical practice, and all cases were classified into two groups: immune thrombocytopenic purpura group and throm-botic thrombocytopenic purpura group accord-ing to their mechanism. Clinical manifestations, results of laboratory examinations, treatment and prognosis of different groups were observed and analyzed.
RESULTS: Twenty four cases of ITP presented hemorrhagic tendency, severe thrombocytope-nia, elevated antiplatelet antibody or platelet related IgG, megacaryocyte hyperplasia. The platelet counts increased after discontinuation of IFNα and treatment with immune suppression agents for 1 or 2 weeks and the prognosis of ITP was good. Three cases of TTP presented fever, decreased platelet count, hemolytic anemia, neu-ropsychological symptoms and renal disorder. Plasma transfusion was the main therapy with poor prognosis and high mortality. ITP and TTP usually occurred in the process of anti- HCV treatment of IFNα.
CONCLUSION: Two kinds of IFNα-induced se-vere thrombocytopenia could occur during the process of anti-virus. Physicians should recog-nize and treat them in time correctly.
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22
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Diaz GC, Prowda J, Lo IJ, Arepally GM, Evans N, Wheeless Y, Samstein B, Guarrera JV, Renz JF. Transplantation-mediated alloimmune thrombocytopenia: Guidelines for utilization of thrombocytopenic donors. Liver Transpl 2008; 14:1803-9. [PMID: 19025920 DOI: 10.1002/lt.21539] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Transplantation-mediated alloimmune thrombocytopenia (TMAT) is donor-derived thrombocytopenia following solid-organ transplantation. To date, no clear consensus on the appropriateness of organ utilization from cadaver donors with a history of idiopathic thrombocytopenia purpura (ITP) has emerged. Herein is reported a devastating case of TMAT following liver transplantation utilizing an allograft from a donor with ITP that resulted in allograft failure. The literature is reviewed in this context to propose preliminary guidelines regarding utilization of allografts from cadaver donors with a history of ITP.
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Affiliation(s)
- Geraldine C Diaz
- Department of Anesthesiology, University of Arizona, Tucson, AZ 85724, USA
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23
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Yokoyama S, Kasahara M, Fukuda A, Morioka D, Mori T, Nakagawa S, Shimizu N, Saito O, Nakagawa A. Evans syndrome after successful living-donor liver transplantation for neonatal giant cell hepatitis. Transplantation 2007; 84:798-9. [PMID: 17893616 DOI: 10.1097/01.tp.0000280544.06865.07] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
MESH Headings
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/therapy
- Anemia, Hemolytic, Autoimmune/virology
- DNA, Viral/blood
- Epstein-Barr Virus Infections/complications
- Epstein-Barr Virus Infections/diagnosis
- Giant Cells/pathology
- Hepatitis/pathology
- Hepatitis/surgery
- Herpesvirus 4, Human/isolation & purification
- Humans
- Immune Tolerance/drug effects
- Infant
- Liver Transplantation
- Living Donors
- Male
- Postoperative Complications/diagnosis
- Postoperative Complications/therapy
- Postoperative Complications/virology
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Purpura, Thrombocytopenic, Idiopathic/virology
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24
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Sharma P, Marrero JA, Fontana RJ, Greenson JK, Conjeevaram H, Su GL, Askari F, Sullivan P, Lok AS. Sustained virologic response to therapy of recurrent hepatitis C after liver transplantation is related to early virologic response and dose adherence. Liver Transpl 2007; 13:1100-8. [PMID: 17377914 DOI: 10.1002/lt.21121] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Sustained virologic response (SVR) after antiviral therapy for recurrent hepatitis C virus (HCV) infection in liver transplant (LT) recipients is consistently lower than that achieved in non-LT patients. We evaluated efficacy and safety of pegylated interferon (IFN) and ribavirin (RBV) therapy in LT recipients with recurrent HCV and factors associated with SVR. All subjects with histologic evidence of recurrent HCV were intended to be treated for 48 weeks with full-dose pegylated IFN; target dose of RBV was 800 mg/day. Thirty-five LT recipients with recurrent HCV, median age 48.5 years, 77% genotype 1, and median pretreatment HCV RNA 6.4 log10 IU/mL were treated between January 2000 and February 2006. Antiviral therapy was discontinued prematurely in 15 subjects as a result of adverse events. Median overall treatment duration was 46 weeks. Early virologic response at week 12 was seen in 17 (49%) and an end-of-treatment virological response in 19 (54%) patients. SVR was achieved in 13 patients (37%), and all 9 patients followed for >1 year after treatment had durable response. Patients with SVR had significantly lower pretreatment HCV RNA (5.7 vs. 6.5 log10 IU/mL, P=0.003), more likely to have a week 12 virological response (85% vs. 27%, P=0.0009) and received higher cumulative doses of pegylated IFN (75% vs. 33%, P=0.029) and RBV (90% vs. 26%, P=0.016) compared with patients whose disease did not respond to therapy. In conclusion, SVR was achieved in 37% of patients with recurrent hepatitis C after LT. Similar to non-LT patients, those with lower pretreatment HCV RNA, a week 12 virological response, and pegylated IFN and RBV dose adherence were more likely to achieve SVR.
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Affiliation(s)
- Pratima Sharma
- University of Michigan Health Systems, Division of Gastroenterology and Department of Pathology, Ann Arbor, MI 48109-0362, USA
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25
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Wei SH, Ho MC, Ni YH, Lin DT, Lee PH. Cytomegalovirus-associated Immune Thrombocytopenic Purpura After Liver Transplantation. J Formos Med Assoc 2007; 106:327-9. [PMID: 17475612 DOI: 10.1016/s0929-6646(09)60261-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Immune thrombocytopenic purpura (ITP) is a rare complication after liver transplantation. Infection with cytomegalovirus (CMV) is a frequent complication of organ transplantation and may induce autoimmune diseases, such as ITP. We report a case of ITP after primary CMV infection in a 3-year-old boy recipient of living-related orthotopic liver transplantation (OLT). The ITP developed 2 years after OLT in this patient who had received tacrolimus as an immunosuppressive agent, with nadir platelet counts of 5000/mm(3) in 2 weeks. The patient was treated with two courses of intravenous gamma globulin (1 g/kg/day for 2 days) and subsequent oral prednisolone (1.3 mg/kg/day for 2 weeks). He recovered from thrombocytopenia 4 weeks later. An inadequate immunosuppression, as evident by the low serum tacrolimus level (5.8 ng/mL before the episode of ITP) in this patient, may allow the development of ITP after CMV infection.
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Affiliation(s)
- Shu-Hao Wei
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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