Blood disorders after kidney transplantation

A are cause of post-renal transplant anemia by parvovirus-B19: Case report

One of the issues during the post-transplant phase is anemia. The increased risk of graft rejection makes evaluating transplant recipients difficult. Parvovirus-B19 (PV-B19) should be considered one of the differential diagnosis of post-transplant anemia (PTA) in renal transplantation recipients. In this article, we report a 32 year old man who was admitted to the hospital with anemia. During the assessment, infection with PV-B19 was confirmed as the cause of the anemia. He received intravenous immunoglobin (IVIG) as the treatment.

Pre-Transplant Frequencies of FoxP3+CD25+ in CD3+CD8+ T Cells as Potential Predictors for CMV in CMV-Intermediate Risk Kidney Transplant Recipients

Cytomegalovirus (CMV) infection detrimentally influences graft survival in kidney transplant recipients, with the risk primarily determined by recipient and donor serostatus. However, recipient CD8+ T cells play a crucial role in CMV control. The optimal preventive strategy (prophylaxis vs. pre-emptive treatment), particularly for seropositive (intermediate risk) recipients, remains uncertain. We investigated CD8+ T cell subpopulation dynamics and CMV occurrence (DNAemia ≥ 100 IU/mL) in 65 kidney transplant recipients, collecting peripheral blood mononuclear cells before (T1) and 1 year after transplantation (T2). Comparing the two timepoints, we found an increase in granulocyte, monocyte and CD3+CD8+ T cells numbers, while FoxP3+CD25+, LAG-3+ and PD-1+ frequencies were reduced at T2. CMV DNAemia occurred in 33 recipients (55.8%) during the first year. Intermediate risk patients were disproportionally affected by posttransplant CMV (N = 29/45, 64.4%). Intermediate risk recipients developing CMV after transplantation exhibited lower leukocyte, monocyte, and granulocyte counts and higher FoxP3+CD25+ frequencies in CD3+CD8+ T cells pre-transplantation compared to patients staying CMV negative. Pre-transplant FoxP3+CD25+ in CD3+CD8+ T cells had the best discriminatory potential for CMV infection prediction within the first year after transplantation (AUC: 0.746). The FoxP3+CD25+ CD3+CD8+ T cell subset may aid in selecting intermediate risk kidney transplant recipients for CMV prophylaxis.

Adverse Drug Events after Kidney Transplantation

Introduction: Kidney transplantation stands out as the optimal treatment for patients with end-stage kidney disease, provided they meet specific criteria for a secure outcome. With the exception of identical twin donor-recipient pairs, lifelong immunosuppression becomes imperative. Unfortunately, immunosuppressant drugs, particularly calcineurin inhibitors like tacrolimus, bring about adverse effects, including nephrotoxicity, diabetes mellitus, hypertension, infections, malignancy, leukopenia, anemia, thrombocytopenia, mouth ulcers, dyslipidemia, and wound complications. Since achieving tolerance is not feasible, patients are compelled to adhere to lifelong immunosuppressive therapies, often involving calcineurin inhibitors, alongside mycophenolic acid or mTOR inhibitors, with or without steroids. Area covered: Notably, these drugs, especially calcineurin inhibitors, possess narrow therapeutic windows, resulting in numerous drug-related side effects. This review focuses on the prevalent immunosuppressive drug-related side effects encountered in kidney transplant recipients, namely nephrotoxicity, post-transplant diabetes mellitus, leukopenia, anemia, dyslipidemia, mouth ulcers, hypertension, and viral reactivations (cytomegalovirus and BK virus). Additionally, other post-kidney-transplantation drugs such as valganciclovir may also contribute to adverse events such as leukopenia. For each side effect, we propose preventive measures and outline appropriate treatment strategies.

Management of drug-induced neutropenia, thrombocytopenia, and anaemia after solid organ transplantation: A comprehensive review

WHAT IS KNOWN AND OBJECTIVE

Advances in the development of more effective immunosuppressive drugs have increased graft survival and drug induced adverse effects. Haematological complications including neutropenia, thrombocytopenia, and anaemia are common side effects that affect the grafts' and patients' outcomes. Several studies have stated the important role of various medications in haematological complications after transplantation. They have reported the incidence and different mechanisms of drug induced cytopenia, as well as an overview of possible treatment modalities. However, there is no comprehensive protocol for the management of these complications following transplantation. This narrative review was performed to develop a comprehensive practical approach for management of drug induced haematological complications following solid organ transplantation.

METHOD

PubMed, Embase, Cochrane library, Web of Science, and Google scholar databases were searched without time limitations until March, 2021. In addition, some valid drug information data bases (Uptodate and Micromedex) were searched for detailed information until October, 2021.

RESULTS AND DISCUSSION

Several immunosuppressive and antimicrobial medications may induce neutropenia, thrombocytopenia or anaemia following transplantation. Most of these agents cause dose-related cytopenia, which resolves with dose reduction or drug withdrawal. However, any change in medications may result in negative consequences such as severe infections, bleeding, cardiovascular complications, acute allograft rejection, and graft or patient loss. Thus, cautious evaluation of the patient's condition and the pharmacological properties of the culprit medication are required.

WHAT IS NEW AND CONCLUSION

Three algorithms are presented to guide healthcare providers in the stepwise management of drug-induced neutropenia, thrombocytopenia, and anaemia after solid organ transplantation.

Pure Red Cell Aplasia in a Renal Transplant Recipient: Case Report and Review of the Literature

Severe anemia requiring multiple blood transfusions in the posttransplant period can trigger rejection. The evaluation of anemia among transplant recipients is a challenging task. Awareness should be continued for tacrolimus to manage pure red cell aplasia, but further evidence is needed to prove whether tacrolimus is a real cause of posttransplant anemia. Our case patient, a 66-year-old male patient with end-stage renal disease due to diabetic nephropathy, underwent a preemptive living donor renal transplant in September 2018. He had received a coronary artery bypass graft with transcatheter aortic valve implantation 3 years before renal transplant. Initially, he was maintained on prednisolone, mycophenolate mofetil, and tacrolimus after basiliximab induction. One month later, he presented with low cardiac output symptoms. His complete blood count showed normocytic normochromic anemia with reticulocytopenia (his hemoglobin level dropped from 112 to 69 g/L), which necessitated regular blood transfusions. His iron profile, serum folate, and vitamin B12 were within normal limits, and he had negative hemolytic and autoimmune screening tests. A bone marrow biopsy revealed acquired pure red cell aplasia, which was most likely drug induced as viral profiles were negative for parvovirus B19, cytomegalovirus, and Epstein-Barr virus. The patient was managed by discontinuing mycophenolate mofetil, and the steroid dose was increased up to 20 mg/day but without improvement. With tacrolimus then considered, 3 weeks after presentation, we replaced tacrolimus with cyclosporine. Complete blood count follow-up showed improvement without any need for further blood transfusions. After 1 month of cyclosporine maintenance, mycophenolate mofetil was resumed with a steady increase of hemoglobin up to 150 g/L and serum creatinine of 122 μmol/L. Pure red cell aplasia is a rare disorder among renal transplant recipients, which could be induced by maintenance tacrolimus therapy.

Febrile neutropenia after kidney transplantation

Neutropenia is common after kidney transplant. There are few data on febrile neutropenia episodes (FNE) after kidney transplant. We studied FNE in a single-center retrospective cohort of 1682 kidney transplant recipients. Neutropenia (absolute neutrophil count [ANC] <1000) occurred in 32% and FNE in 3%. There were 56 FNE. Median time to FNE was 143 days, and median time from onset of neutropenia to onset of FNE was 5.5 days. The most common sources of infection were urine, blood, and lungs, and in 20% of FNE no source was identified. No infectious organism was identified in 46% of FNE, and opportunistic infections were uncommon. Patient survival was similar among those with and without FNE, but FNE was associated with increased death-censored graft failure (DCGF). Following FNE, acute rejection occurred in 31% and DCGF in 15%, often in the setting of persistent reduced immunosuppression. In conclusion, FNE are common after kidney transplant and are associated with inferior long-term outcomes.

Short- and long-term impact of neutropenia within the first year after kidney transplantation

The aim of this retrospective single-center study was to investigate short- and long-term impact of neutropenia occurring within the first year after kidney transplantation, with a special emphasis on different neutropenia grades. In this unselected cohort, 225/721 patients (31%) developed 357 neutropenic episodes within the first year post-transplant. Based on the nadir neutrophil count, patients were grouped as neutropenia grade 2 (<1.5-1.0*10⁹ /L; n=105), grade 3 (<1.0-0.5*10⁹ /L; n=65), and grade 4 (<0.5*10⁹ /L; n=55). Most neutropenia episodes were presumably drug-related (71%) and managed by reduction/discontinuation of potentially responsible drugs (mycophenolic acid [MPA] 51%, valganciclovir 25%, trimethoprim/sulfamethoxazole 19%). Steroids were added/increased as replacement for reduced/discontinued MPA. Granulocyte colony-stimulating factor was only used in 2/357 neutropenia episodes (0.6%). One-year incidence of (sub)clinical rejection, one-year mortality as well as long-term patient and graft survival were not different among patient without neutropenia and neutropenia grade 2/3/4. However, the incidence of infections was about 3-times higher during neutropenia grade 3 and 4, but not increased during grade 2. In conclusion, neutropenia within the first year after kidney transplantation represents no increased risk for rejection and has no negative impact on long-term patient and graft survival. Adding/increasing steroids as replacement for reduced/discontinued MPA might supplement management of neutropenia.

Predictors and Complications of Post Kidney Transplant Leukopenia

BACKGROUND

Leukopenia occurs frequently following kidney transplantation and is associated with adverse clinical outcomes including increased infectious risk. In this study we sought to characterize the causes and complications of leukopenia following kidney transplantation.

METHODS

In a cohort of adult patients (≥18 years) who underwent kidney transplant from Jan 2006-Dec 2017, we used univariable Cox proportional Hazards models to identify predictors of post-transplant leukopenia (WBC < 3500 mm³). Factors associated with post-transplant leukopenia were then included in a multivariable backwards stepwise selection process to create a prediction model for the outcome of interest. Cox regression analyses were subsequently used to determine if post-transplant leukopenia was associated with complications.

RESULTS

Of 388 recipients, 152 (39%) developed posttransplant leukopenia. Factors associated with leukopenia included antithymocyte globulin as induction therapy (HR 3.32, 95% CI 2.25-4.91), valganciclovir (HR 1.84, 95% CI 1.25-2.70), tacrolimus (HR 3.05, 95% CI 1.08-8.55), prior blood transfusion (HR 1.17 per unit, 95% CI 1.09- 1.25), and donor age (HR 1.02 per year, 95% CI 1.00-1.03). Cytomegalovirus infection occurred in 26 patients with leukopenia (17.1%). Other than cytomegalovirus, leukopenia was not associated with posttransplant complications.

CONCLUSION

Leukopenia commonly occurred posttransplant and was associated with modifiable and non-modifiable pretransplant factors.

Post-transplant erythrocytosis after kidney transplantation: A review

Post-transplant erythrocytosis (PTE) is defined as persistently elevated hemoglobin > 17 g/dL or hematocrit levels > 51% following kidney transplantation, independent of duration. It is a relatively common complication within 8 months to 24 months post-transplantation, occurring in 8%-15% of kidney transplant recipients. Established PTE risk factors include male gender, normal hemoglobin/hematocrit pre-transplant (suggestive of robust native kidney erythropoietin production), renal artery stenosis, patients with a well-functioning graft, and dialysis before transplantation. Many factors play a role in the development of PTE, however, underlying endogenous erythropoietin secretion pre-and post-transplant is significant. Other contributory factors include the renin-angiotensin- aldosterone system, insulin-like growth factors, endogenous androgens, and local renal hypoxia. Most patients with PTE experience mild symptoms like malaise, headache, fatigue, and dizziness. While prior investigations showed an increased risk of thromboembolic events, more recent evidence tells a different story-that PTE perhaps has lessened risk of thromboembolic events or negative graft outcomes than previously thought. In the evaluation of PTE, it is important to exclude other causes of erythrocytosis including malignancy before treatment. Angiotensin converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARBs) are the mainstays of treatment. Increased ACE-I/ARB use has likely contributed to the falling incidence of erythrocytosis. In this review article, we summarize the current literature in the field of post-transplant erythrocytosis after kidney transplantation.

[Treatment-refractory anaemia in a 35-year-old heart transplant recipient on chronic hemodialysis]

Es wird über einen 35-jährigen Dialysepatienten nach Herztransplantation berichtet, der eine „pure red cell aplasia“ aufwies. Serologisch fand sich ein positiver Parvovirus-B19-Immunglobulin-M-Titer, im Direktnachweis mittels Polymerase-Kettenreaktion zeigten sich 80 Mrd. IU/ml. In der zytologischen Untersuchung des Knochenmarks gelang der Nachweis von Riesenproerythroblasten, pathognomonisch für eine Parvovirus-B19-Infektion. Zur Therapie erfolgte die hoch dosierte Gabe von Immunglobulinen über 5 Tage. Bei Wiedervorstellung nach vier Wochen zeigte sich die Anämie deutlich gebessert. Bei Patienten nach Organtransplantation mit hyporegenerativer Anämie sollte eine Parvovirus-B19-Infektion stets ausgeschlossen werden.

Incidence, risk factors, and outcomes of post-transplant erythrocytosis after kidney transplantation

The incidence, risk factors, and outcomes of kidney transplant recipients (KTRs) with post-transplant erythrocytosis (PTE) in the modern era of strong, protocolized immunosuppressive management are unknown. In this study, we aim to identify the incidence and risk factors of PTE and outcomes associated with PTE. This study examined adult KTRs transplanted at our hospital between 01/2001 and 12/2016. Controls were KTRs without PTE and selected in a 1:5 ratio using incident density sampling. Patient survival, graft survival, and vascular thromboembolism (VTE) incidence were outcomes of interest. Of 4,317 kidney transplants during the study period, 214 (5%) had PTE and were compared with controls. In the multivariate analysis, recipients with older age (HR: 0.97, 95% CI 0.96-0.99, p = .001) were less likely to develop PTE, while male gender (HR: 3.2; 95% CI: 1.92-5.3, p < .001) and non-preemptive transplant (HR: 3.86, 95% CI 1.56-9.56, p = .003) were associated with increased risk of PTE. After adjustment for confounding factors, PTE was not associated with patient mortality (HR: 0.99, 95% CI 0.69-1.42, p = .97), graft failure (HR: 1.11, 95% CI 0.68-1.80, p = .69), or VTE (HR: 1.07, 95% CI 0.59-1.96, p = .81). The incidence of PTE is still substantial in this era, but with proper management PTE does not impact patient or graft survival.

Anemia after kidney transplantation: Does its basis differ from anemia in chronic kidney disease?

BACKGROUND

Although similar factors play a role in both PTA and anemia in patients with CKD, additional risk factors exist in the pathogenesis of PTA. The present study aimed at comparing anemia and inflammation-related parameters between RTx recipients and CKD patients and elucidating the risk factors of PTA.

METHODS

This single-centered, cross-sectional study consisted of 68 participants: 48 were in the RTx group and 20 were in the CKD group. The CKD patients were comparable to the RTx recipients in terms of age, gender, and eGFR. Serum levels of EPO, hepcidin, and IL-6 were measured by enzyme-linked immunosorbent assays. The ratio of EPO/Hb was calculated to estimate endogenous EPO resistance.

RESULTS

The prevalence of anemia was 46% in the RTx group and 30% in the CKD group (P = .23). RTx recipients had significantly lower Hb (P = .04), higher EPO (P < .001), and ferritin levels (P = .001), and higher EPO/Hb ratios (P < .001); however, CKD patients showed a higher frequency of absolute iron deficiency (P = .008). Neither hepcidin nor IL-6 levels differed between the two groups. Hb level of RTx recipients was correlated with only eGFR (r = .437, P = .002) but not with any of the transplantation-related factors, while Fe level was the only parameter to be correlated with Hb level of CKD patients (r = .622, P = .01).

CONCLUSION

In the present study comparing GFR-matched RTx and CKD patients, lower GFR level appears to be the factor most strongly associated with anemia, and endogenous EPO resistance is among the contributing factors to PTA.

Influence of Calcineurin Inhibitor and Sex on Mycophenolic Acid Pharmacokinetics and Adverse Effects Post-Renal Transplant

Tacrolimus or cyclosporine is prescribed with mycophenolic acid posttransplant and contributes to interpatient variability in mycophenolic acid pharmacokinetics and response. Cyclosporine inhibits enterohepatic circulation of the metabolite mycophenolic acid glucuronide, which is not described with tacrolimus. This study investigated mycophenolic acid pharmacokinetics and adverse effects in stable renal transplant recipients and the association with calcineurin inhibitors, sex, and race. Mycophenolic acid and mycophenolic acid glucuronide area under the concentration-time curve from 0 to 12 hours (AUC0-12h ) and apparent clearance were determined at steady state in 80 patients receiving cyclosporine with mycophenolate mofetil and 67 patients receiving tacrolimus with mycophenolate sodium. Gastrointestinal adverse effects and hematologic parameters were evaluated. Statistical models evaluated mycophenolic acid pharmacokinetics and adverse effects. Mycophenolic acid AUC0-12h was 1.70-fold greater with tacrolimus (68.9 ± 30.9 mg·h/L) relative to cyclosporine (40.8 ± 17.6 mg·h/L); P < .001. Target mycophenolic acid AUC0-12h of 30-60 mg·h/L was achieved in 56.3% on cyclosporine compared with 34.3% receiving tacrolimus (P < .001). Mycophenolic acid clearance was 48% slower with tacrolimus (10.6 ± 4.7 L/h) relative to cyclosporine (20.5 ± 10.0 L/h); P < .001. Enterohepatic circulation occurred less frequently with cyclosporine (45%) compared with tacrolimus (78%); P < 0.001; with a 2.9-fold greater mycophenolic acid glucuronide AUC0-12h to mycophenolic acid AUC0-12h ratio (P < .001). Race did not affect mycophenolic acid pharmacokinetics. Gastrointestinal adverse effect scores were 2.2-fold higher with tacrolimus (P < .001) and more prominent in women (P = .017). Lymphopenia was more prevalent with tacrolimus (52.2%) than cyclosporine (22.5%); P < 0.001. Calcineurin inhibitors and sex contributed to interpatient variability in mycophenolic acid pharmacokinetics and adverse effects post-renal transplant, which could be attributed to differences in enterohepatic circulation.

Anaplasma phagocytophilum presenting with orchitis in a renal transplant recipient

Human granulocytic anaplasmosis (HGA), caused by Anaplasma phagocytophilum, is an emerging tick-borne disease. It is spread by the black-legged deer tick Ixodes scapularis that serves as the vector for six human pathogens. HGA is still rarely reported in solid organ transplant recipients. In solid organ transplant recipients, orchitis has been reported secondary to chickenpox, tuberculosis and infections due to Listeria monocytogenes and Nocardia asteroides. Orchitis as a presenting feature of HGA infection has only been reported in animals. We present a unique case of a renal transplant recipient with HGA that presented as orchitis. We also compare the clinical presentation and laboratory findings of our patient with other cases of HGA in transplant recipients. To the best of our knowledge, our patient is one of the first cases of A phagocytophilum mono-infection causing a classical presentation of orchitis in a transplant patient.

Analysis of genetic and clinical risk factors of post-transplant thrombocytopenia in kidney allograft recipients

BACKGROUND

Hematological abnormalities after transplantation are complications that may arise after renal transplantation, of which thrombocytopenia is associated with increased risk of bleeding and other complications. The development of thrombocytopenia is affected by various clinical conditions, and the stromal-derived factor 1 (SDF1) and platelet factor 4 (PF4) genes are known to be involved in the production or destruction of platelets. The purpose of this study was to investigate the prevalence of posttransplant thrombocytopenia and its association with other clinical conditions and genetic polymorphisms of SDF1 and PF4 genes a long time after transplantation.

METHODS

This is a retrospective study that includes a total of 305 kidney transplant (KT) recipients between 2008 and 2012 at St. Vincent Medical Center, Los Angeles, CA. In this study, posttransplant thrombocytopenia was defined as a 30% reduction in platelet count from the baseline in the first week or a decrease of <100 (×10³/μL) within 1 year after KT. The subjects were divided into posttransplant thrombocytopenia and control groups. The chi-square test, t-test, and logistic regression were used for the analyses.

RESULTS

In the first week, 65 patients had a 30% reduction in platelet count (21.3%). Gender, simultaneous kidney-pancreas transplantation, induction therapy (IT), and only alleles of rs2297630 of SDF1, among the SDF1 and PF4 genes, showed statistically significant differences. The rs2297630 alleles were consistently significant risk factors (non G vs. G: odds ratio = 0.445; 95% confidence interval, 0.224-0.884; p = .021) in the multiple logistic regression. In the 1-year study, 61 patients (20.0%) had platelet counts of <100 × 10³/μL and had statistically significant differences in patients who had delayed graft function and induction therapy.

CONCLUSIONS

In this study, non-G group of rs2297630 in SDF1 significantly increased the risk of post-transplant thrombocytopenia in the first week of kidney transplantation.

Effect of Age on Leukopenia Following Renal Transplantation at a Single Center

Introduction:

Leukopenia in renal transplant recipients occurs commonly within the first year following transplantation; however, literature on the effects of age on leukopenia is scarce.

Design:

A single-center, retrospective review was conducted on 141 recipients transplanted from January 2011 to December 2015. Transplant recipients were characterized by age <60 years (n = 94) or age 60 years and older (n = 47) for analysis.

Results:

A greater incidence of leukopenia was seen in the older cohort compared to the younger cohort (64% vs 55%). Of those patients who developed leukopenia, the older cohort (n = 30) had a higher incidence of hospitalization for leukopenia (30% vs 23%) but a lower incidence of hospitalization for infection (20% vs 25%) compared to the younger cohort (n = 52). Additionally, one month following mycophenolate mofetil (MMF) discontinuation, the older cohort had reduced recovery of their white blood cell count (+263.8% vs +272.5%) and experienced less recurrent leukopenic episodes (50% vs 67%) and rejection episodes (0% vs 22%) compared to the younger cohort, alluding to the need for less immunosuppression.

Conclusions:

Age at transplantation was not associated with the development of leukopenia; however, older patients had a higher incidence of leukopenia and hospitalization for leukopenia. Dose reduction or discontinuation of MMF should be considered in older kidney transplant recipients who develop leukopenia.

Factors associated with anaemia in kidney transplant recipients in the first year after transplantation: a cross-sectional study

Background

Anaemia after kidney transplantation may reduce quality of life, graft or patient survival. We aimed to determine the prevalence and risk factors for anaemia in the initial 12 months after transplantation.

Methods

We conducted a cross-sectional study at 6 and 12 months after transplantation. Anaemia was defined by World Health Organization criteria taking into consideration erythropoietin use. Logistic regression was used to determine the association between demographic, clinical and pharmacological risk factors for the main outcome of moderate-severe anaemia.

Results

A total of 336 transplant recipients were included and the prevalence of moderate-severe anaemia was 27.4% at 6 months and 15.2% at 12 months. Lower kidney function, female gender, transferrin saturation below 10% and proteinuria were associated with moderate-severe anaemia at both time points. Recent intravenous immunoglobulin treatment was associated with anaemia at 6 months. Recent infection and acute rejection were also associated with anaemia 12 months. Around 20% of patients had at least one blood transfusion but they were uncommon beyond 3 months.

Conclusions

Anaemia remains highly prevalent requiring treatment with erythropoietin and transfusions. Most identifiable risk factors relate to clinical problems rather than pharmacological management, while markers of iron-deficiency remain difficult to interpret in this setting.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-1054-7) contains supplementary material, which is available to authorized users.

Risk factors, survival, and impact of prophylaxis length in cytomegalovirus-seropositive lung transplant recipients: A prospective, observational, multicenter study

BACKGROUND

The optimal length of cytomegalovirus (CMV) prophylaxis in lung transplantation according to CMV serostatus is not well established.

METHODS

We have performed a prospective, observational, multicenter study to determine the incidence of CMV infection and disease in 92 CMV-seropositive lung transplant recipients (LTR), their related outcomes and risk factors, and the impact of prophylaxis length.

RESULTS

At 18 months post transplantation, 37 patients (40%) developed CMV infection (23 [25%]) or disease (14 [15.2%]). Overall mortality was higher in patients with CMV disease (64.3% vs 10.2%; P<.001), but only one patient died from CMV disease. In the multivariate analysis, CMV disease was an independent death risk factor (odds ratio [OR] 18.214, 95% confidence interval [CI] 4.120-80.527; P<.001). CMV disease incidence was higher in patients with 90-day prophylaxis than in those with 180-day prophylaxis (31.3% vs 11.8%; P=.049). Prophylaxis length was an independent risk factor for CMV disease (OR 4.974, 95% CI 1.231-20.094; P=.024). Sixteen patients withdrew from prophylaxis because of adverse events.

CONCLUSION

CMV infection and disease in CMV-seropositive LTR remain frequent despite current prophylaxis. CMV disease increases mortality, whereas 180-day prophylaxis reduces the incidence of CMV disease.

Anemia and low-grade inflammation in pediatric kidney transplant recipients

BACKGROUND

Anemia and low-grade inflammation are reported to be associated with impaired long-term graft outcome in renal transplant (RTx) recipients. In this study, hemoglobin (Hb) and inflammation marker levels were correlated with measured glomerular filtration rate (GFR) in 128 pediatric RTx recipients over a median follow-up period of 10 years.

METHODS

Serum levels of erythropoietin (EPO), hepcidin-25, high-sensitivity C-reactive protein (CRP) (hsCRP) and interleukin-6 (IL-6) were analyzed by enzyme-linked immunosorbent assays, and GFR was analyzed by ⁵¹Cr-EDTA clearance.

RESULTS

The median levels of Hb (115 g/L), hsCRP (0.4 mg/L) and IL-6 (1.4 pg/mL) and the median erythrocyte sedimentation rate (ESR; 19 mm/h) remained stable after the first post-operative year. However, approximately half of the patients had a normocytic, normochromic anemia, and one-third had elevated levels of hsCRP (>1 mg/L) and ESR (>25 mm/h), indicating continuous low-grade inflammation. Low Hb levels preceded increased fibrosis in protocol biopsies taken at 1.5 and 3 years after transplantation and preceded decreased GFR by several years. Hb levels showed an inverse correlation with EPO levels (r = -0.206, p = 0.038) and ESR (r = -0.369, p < 0.001), but not with hepcidin-25, hsCRP or IL-6 levels. The levels of the major inflammatory markers IL-6 and hsCRP did not show a significant correlation with GFR at either the early maintenance phase or later. In the multivariable analysis, low Hb levels performed better than any other marker with respect to predicting concomitant and subsequent GFR.

CONCLUSIONS

Anemia, but not elevated inflammatory indices, was associated with poor concomitant and subsequent graft function during a 10-year follow-up in pediatric RTx patients.

Cytopenia Occurrence in Kidney Transplant Recipients Within Early Post-transplant Period

Objective:

This study assessed incidence, severity, and time to occurrence of drug-induced leukopenia/thrombocytopenia within 1^st month after kidney transplantation.

Methods:

This cross-sectional study was conducted on newly kidney transplant recipients from two hospitals, Iran. Patients with thrombocytopenia due to acute antibody-mediated rejection were excluded from the study. Demographic, clinical, and laboratory data of patients within the 1^st month after transplantation were collected.

Findings:

Of 213 patients, 14.1% and 66.2% experienced leukopenia and thrombocytopenia, respectively. Cytopenia happened more commonly among patients with thymoglobulin-containing regimen (for leukopenia: 24.6% vs. 0%, P < 0.001; for thrombocytopenia 84.4% vs. 41.8%, P < 0.001). Most leukopenia patients experienced Grades 1 and 2 of leukopenia (46.6% and 40% of patients). Most thrombocytopenic patients showed Grade 1 of thrombocytopenia (78.7%). Cumulative dose of thymoglobulin did not differ between patients with and without leukopenia (5.57 ± 1.13 vs. 5.9 ± 1.96 mg/kg; P = 0.613) or with and without thrombocytopenia (5.87 ± 1.86 vs. 5.56 ± 1.38 mg/kg; P = 0.29). Cytopenia were more common among recipients from deceased compared with from living donors (91.3% vs. 8.7% for leukopenia patients, P = 0.001; 69.9% vs. 33.1% for thrombocytopenia, P = 0.02). More patients with kidney from deceased donors received thymoglobulin in their immunosuppressive regimen (82% vs. 37%; P < 0.001). The median time to leukopenia and thrombocytopenia were 3 days and 1 day, respectively.

Conclusion:

Among immunosuppressive and prophylactic antimicrobial agents, thymoglobulin is more related to cytopenia; therefore, thymoglobulin dose reduction is recommended as the first intervention to manage cytopenia without need for reduction of its cumulative dose. The higher prevalence of cytopenia among recipients from deceased donors may be related to the higher use of thymoglobulin in these patients.

Anemia and markers of erythropoiesis in pediatric kidney transplant recipients compared to children with chronic renal failure

PTA and anemia of CKD share a similar pathogenesis. However, PTA may be disproportionate to the reduction in the GFR. Data relating to the mechanism of PTA are scarce. We evaluated the erythropoiesis parameters in pediatric kidney recipients compared to children with CKD. A total of 100 patients (54 post-kidney TX, 46 with CKD) were enrolled in the single-center cohort study. GFR was found to be significantly lower in the CKD group (49.7±22.4 vs 72.9±28.5 mL/min/1.73 m², P<.001); anemia was significantly more common in the TX patients (52% vs 41.3%, P<.001). Iron transferrin saturation and serum ferritin levels were lower in the CKD patients. In both groups, hemoglobin Z scores significantly correlated with GFR (R=.31, P=.07). This correlation was more prominent in the CKD group (R=.43, P=.008) compared to the TX group (R=.31, P=.04). Anemia was significantly more common in the TX patients than in the CKD patients despite a better GFR. The higher prevalence of anemia in the TX group could not be explained by an iron deficiency or reduced EPO production. We speculate that immunosuppressive therapy together with resistance to EPO may play a role in the pathogenesis of post-transplantation anemia.

Neutrophil-Lymphocyte Ratio Is Significantly Decreased in Preemptive Renal Transplant Patients

AIM

Cardiovascular diseases and infections are the leading two causes of morbidity and mortality in end-stage renal disease (ESRD) patients. Kidney transplantation is the preferred method for renal replacement owing to better survival. There are reports of irreversibly damaged immune system in dialysis patients, which did not return to normal even after kidney transplantation. The neutrophil-lymphocyte ratio (NLR) is an easily applicable method for evaluation of inflammation. We hypothesized that preemptive kidney transplantation can improve inflammatory state compared with nonpreemptive recipients. To test our hypothesis, we retrospectively investigated pretransplant and posttransplant NLR and C-reactive protein (CRP) levels of ESRD patients and compared them with values in healthy controls.

MATERIALS AND METHODS

We retrospectively analyzed NLR, CRP, and other hematologic parameters of ESRD patients who were transplanted between January 2005 and January 2014 on the day of transplantation and at the end of first year. We grouped the patients as preemptive and nonpreemptive ones. We excluded patients with coronary artery disease, obesity, hypotension, hyperthyroidism, uncontrolled diabetes mellitus, hematologic or solid organ cancers, and active documented infection at any evaluation period.

RESULTS

We included 137 ESRD patient and 34 healthy control individual in our study. Of the 137 ESRD patients, 52 (38%) were transplanted preemptively. Of the patients, 85 were already on either hemodialysis or peritoneal dialysis therapy at the time of transplantation. The white blood cell count value of the patient and control group (7246.72 ± 1460.26 and 76661.76 ± 1286.29, respectively; P = .43), NLR of the control group was significantly lower than patient group (1.98 ± 0.94 and 3.47 ± 2.33, respectively; P = .007). The NLR of the preemptive group was decreased substantially at the end of first year posttransplantation, the NLR of the preemptive group was significantly lower than the nonpreemptive group (3.08 ± 1.32 and 3.71 ± 2.33; P = .01).

CONCLUSIONS

We showed that all ESRD patients had an increased inflammation rate according to CRP and NLR when compared with healthy controls. We also found that improvement of inflammatory state in preemptive patients is significantly better than nonpreemptive patients at the end of first year evaluation.

Blood disorders typically associated with renal transplantation

Renal transplantation has become one of the most common surgical procedures performed to replace a diseased kidney with a healthy kidney from a donor. It can help patients with kidney failure live decades longer. However, renal transplantation also faces a risk of developing various blood disorders. The blood disorders typically associated with renal transplantation can be divided into two main categories: (1) Common disorders including post-transplant anemia (PTA), post-transplant lymphoproliferative disorder (PTLD), post-transplant erythrocytosis (PTE), and post-transplant cytopenias (PTC, leukopenia/neutropenia, thrombocytopenia, and pancytopenia); and (2) Uncommon but serious disorders including hemophagocytic syndrome (HPS), thrombotic microangiopathy (TMA), therapy-related myelodysplasia (t-MDS), and therapy-related acute myeloid leukemia (t-AML). Although many etiological factors involve the development of post-transplant blood disorders, immunosuppressive agents, and viral infections could be the two major contributors to most blood disorders and cause hematological abnormalities and immunodeficiency by suppressing hematopoietic function of bone marrow. Hematological abnormalities and immunodeficiency will result in severe clinical outcomes in renal transplant recipients. Understanding how blood disorders develop will help cure these life-threatening complications. A potential therapeutic strategy against post-transplant blood disorders should focus on tapering immunosuppression or replacing myelotoxic immunosuppressive drugs with lower toxic alternatives, recognizing and treating promptly the etiological virus, bacteria, or protozoan, restoring both hematopoietic function of bone marrow and normal blood counts, and improving kidney graft survival.

Post-renal transplant erythrocytosis: a case report

PTE is defined as hematocrit >51% or hemoglobin >17 g/dL after renal transplantation. Risk factors include native kidneys with adequate erythropoiesis pretransplant, smoking, renal artery stenosis, and cyclosporine treatment. We report the case of a 14-yr-old female kidney transplant patient, with triple therapy immunosuppression and stable graft function who developed PTE at 12 months post-transplant with hemoglobin 17.3 g/dL, hematocrit 54.2%, stable graft function, and normotensive with normal cardiac echocardiogram and erythropoietin levels. The only risk factor found was tobacco use. As she had no spontaneous improvement, enalapril treatment was started at 19 months post-transplant with a hemoglobin level of 17.5 g/dL and hematocrit 53%; by 23 months post-transplant, hemoglobin lowered to 15 g/dL and hematocrit to 44.5% and continued to be in normal range thereafter. PTE is a rare condition in childhood and can be successfully treated with enalapril.