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Hegland NØ, Rezahosseini O, Pedersen CR, Møller DL, Bugge TB, Wareham NE, Arentoft NS, Hillingsø J, Lund TK, Rasmussen A, Nielsen SD. Anemia in liver transplant recipients: prevalence, severity, risk factors, and survival. APMIS 2024; 132:152-160. [PMID: 38084017 DOI: 10.1111/apm.13364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/11/2023] [Indexed: 02/17/2024]
Abstract
Information about anemia in liver transplant (LTx) recipients is scarce. We investigated the prevalence and severity of anemia before and within the first-year post-LTx, risk factors for having anemia before LTx, and 1-year survival according to anemia status before LTx. This retrospective cohort study received data from The Knowledge Center for Transplantation database at Rigshospitalet, Copenhagen, Denmark. Uni- and multivariate logistic regression were used to investigate factors associated with anemia and a Kaplan-Meier plot to illustrate the probability of survival. We included 346 first-time adult LTx recipients. The median age was 50 years (IQR: 42-57), and 203 (59%) were male. The prevalence of anemia before and 1-year post-LTx were 69 and 45%, respectively. Male sex (aOR 4.0 [95% CI: 2.2-7.2]; p < 0.001) and each unit increase in MELD score (aOR 1.2 [95% CI: 1.1-1.2]; p < 0.001) were positively associated with anemia before LTx. Compared to autoimmune liver diseases, LTx recipients with fulminant hepatic failure (aOR 0.03 [0.00-0.17]; p = 0.001) had lower odds for anemia. The 1-year survival in LTx recipients who had and did not have anemia before transplantation were 93 and 91% (p = 0.47). Anemia was frequent among LTx recipients, and anemia before LTx did not affect 1-year survival.
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Affiliation(s)
- Nina Øksnes Hegland
- Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Omid Rezahosseini
- Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Christian Ross Pedersen
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Dina Leth Møller
- Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Terese Brun Bugge
- Department of Cardiology, Section for Lung Transplantation, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Neval Ete Wareham
- Centre of Excellence for Health, Immunity, and Infections (CHIP), Copenhagen University Hospital/Rigshospitalet, Copenhagen, Denmark
| | - Nicoline Stender Arentoft
- Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Jens Hillingsø
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Kromann Lund
- Department of Cardiology, Section for Lung Transplantation, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Allan Rasmussen
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Susanne Dam Nielsen
- Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
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Tang Y, Guo J, Zhou J, Wan Z, Li J, Qiu T. Risk factors and current state of therapy for anemia after kidney transplantation. Front Med (Lausanne) 2024; 10:1170100. [PMID: 38264045 PMCID: PMC10804853 DOI: 10.3389/fmed.2023.1170100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 12/19/2023] [Indexed: 01/25/2024] Open
Abstract
Post-transplant anemia is one of the most common complications in kidney transplant recipients, severely affecting patient prognosis and quality of life, and is an independent predictor of graft kidney loss and patient mortality. However, our clinical understanding and the attention given to post-transplant anemia are currently insufficient. This paper reviews the current status, risk factors, and therapeutic progress in anemia after transplantation in kidney transplant recipients. We recommend that clinical staff pay attention to anemia and its complications in kidney transplant recipients and intervene early for anemia.
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Affiliation(s)
- Yan Tang
- The Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Jiayu Guo
- The Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Jiangqiao Zhou
- The Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Zijie Wan
- The Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Jinke Li
- The Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Tao Qiu
- The Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
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3
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Mahalwar G, Mathew RO, Rangaswami J. Sodium-glucose cotransporter 2 inhibitors and cardiorenal outcomes in kidney transplantation. Curr Opin Nephrol Hypertens 2024; 33:53-60. [PMID: 38014999 DOI: 10.1097/mnh.0000000000000948] [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: 11/29/2023]
Abstract
PURPOSE OF REVIEW This review aims to explore the current evidence regarding cardiovascular and kidney outcomes in patients who undergo treatment with sodium-glucose cotransporter 2 inhibitors (SGLT2i) post kidney transplantation. RECENT FINDINGS Summary findings from individual studies included in this review showed largely favorable results in the kidney transplant recipients (KTRs) being treated with SGLT2i.These outcomes included parameters such as allograft function, glycemic control, proteinuria, blood pressure, weight loss and safety profile, among others. Almost all the studies reported an initial 'dip' in eGFR, followed by recovery, after the initiation of SGLT2i treatment. None of the studies reported significant interaction of SGLT2i with immunosuppressive medications. The most common adverse effects noted in these studies were infection-related including UTI and genital mycosis. None of the studies reported acute graft rejection attributable to SGLT2i therapy. SUMMARY SGLT2i can play a significant role in improving health outcomes in KTRs. However, clinical trials with larger representation of KTRs longer follow-up period are needed to draw more substantial conclusions.
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Affiliation(s)
- Gauranga Mahalwar
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Roy O Mathew
- Department of Nephrology, Loma Linda VA Healthcare System, Loma Linda
- Loma Linda University School of Medicine, Loma Linda, California
| | - Janani Rangaswami
- Department of Nephrology, Washington DC Veterans Affairs Medical Center
- George Washington University School of Medicine and Health Sciences, Washington DC, USA
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4
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Solis J, Wilson N, Sam T, Ma TW, Yango A, Fischbach B, Kataria AD. Weight-based vs fixed dosing of darbepoetin alfa for anemia following kidney transplantation. Am J Health Syst Pharm 2023; 80:1542-1549. [PMID: 37471466 DOI: 10.1093/ajhp/zxad163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Indexed: 07/22/2023] Open
Abstract
PURPOSE Post-transplantation anemia (PTA) is common in kidney transplant recipients, with patients frequently treated with erythropoietin-stimulating agents such as darbepoetin alfa. The optimal dosing for darbepoetin alfa remains controversial. METHODS This retrospective cohort study involved kidney transplant recipients who received darbepoetin alfa at 2 clinics. Patients were stratified into 2 groups: those who received a fixed dose of 200 μg and those who received a weight-based dose of 0.45 μg/kg. The dosing interval varied depending on clinical response, clinic visit timing, and frequency allowed by insurance. The primary outcome was achieving a hemoglobin concentration of at least 10 g/dL without blood transfusion by 12 weeks after darbepoetin alfa initiation. RESULTS Of the 110 patients in the study, 45% received weight-based dosing and 55% received fixed dosing. Darbepoetin alfa was initiated significantly earlier after transplantation in the fixed-dose group (median of 14 vs 20 days; P = 0.003). The weight-based group received more doses of darbepoetin alfa (median of 4 vs 2 doses; P = 0.002) and had a significantly lower cumulative exposure to darbepoetin alfa (125 vs 590 μg; P < 0.001). The median time between doses was 9 days (interquartile range, 7-14 days) in the weight-based group and 12 days (7-32 days) in the fixed-dose group (P = 0.04). Patients in the weight-based group more frequently achieved the primary outcome (67.3% vs 47.5%; P = 0.059). There was no significant difference in secondary or safety outcomes between the groups. CONCLUSION Weight-based and fixed dosing approaches for darbepoetin alfa were not different in the achievement of a hemoglobin concentration of at least 10 g/dL without blood transfusion at 12 weeks after darbepoetin alfa initiation, with significantly lower cumulative darbepoetin alfa utilization in the weight-based group. Weight-based dosing of darbepoetin alfa in PTA appears to be safe and effective, with the potential for significant patient and health-system cost savings.
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Affiliation(s)
| | | | - Teena Sam
- Baylor University Medical Center, Dallas, TX, USA
| | - Tsung-Wei Ma
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, TX, USA
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Guzzo I, Atkinson MA. Anemia after kidney transplantation. Pediatr Nephrol 2023; 38:3265-3273. [PMID: 36282330 PMCID: PMC10126210 DOI: 10.1007/s00467-022-05743-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/04/2022] [Accepted: 08/31/2022] [Indexed: 01/05/2023]
Abstract
Anemia is a frequent complication in pediatric kidney transplant recipients (KTR) with a variable reported prevalence estimated between 20 and 80% depending on how defined. Causes of and risk factors for post-transplantation anemia (PTA) are multifactorial with iron deficiency being the primary cause of early PTA (within the first 6 months after transplantation) and impaired glomerular filtration rate (GFR) commonly responsible for late PTA (after 6 months). Medications, viral infections, chronic inflammation, and comorbidities also play a role. PTA has relevant long-term consequences and is a potential risk factor for allograft dysfunction, cardiovascular morbidity, and mortality. Thus, an anemia evaluation, approximately 3 months post-transplantation, is recommended in order to start early treatment and improve prognosis. Iron status, vitamin B12, folate, markers of hemolysis, and viral PCR should be checked, and medications, in particular combinations of medications, should be carefully evaluated. PTA treatment may be challenging and should be directed to the underlying causes. Iron supplementation and erythropoietin therapy, not extensively used in KTR, may be indicated. Every effort should be made to avoid blood transfusions in the pre-transplant period to avoid allosensitization. Anemia should be corrected to prepare candidates for kidney transplantation in order to reduce the need for perioperative blood transfusions as well.
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Affiliation(s)
- Isabella Guzzo
- Division of Nephrology and Dialysis, Department of Pediatrics, Bambino Gesù Children's Hospital and Research Institute, Piazza Sant'Onofrio 4, 00165, Rome, Italy
| | - Meredith A Atkinson
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Yeom JH, Kim W, Kang KP, Kim H, Yu HC, Hwang HP, Chung BH, Jang KY, Lee S. Graft lymphoma in a kidney transplant recipient: a case report. KOREAN JOURNAL OF TRANSPLANTATION 2023; 37:216-219. [PMID: 37697494 PMCID: PMC10583984 DOI: 10.4285/kjt.23.0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/30/2023] [Accepted: 08/04/2023] [Indexed: 09/13/2023] Open
Abstract
Posttransplant lymphoproliferative disorders (PTLDs) are severe complications with heterogeneous clinical pictures involving abnormal lymphoproliferation in solid organ transplants and are known to be closely associated with Epstein-Barr virus (EBV) infection. Herein, we present a case of graft lymphoma in a febrile kidney transplant recipient. A 37-year-old woman was admitted with an abrupt 39 °C fever, mild graft discomfort, and gross hematuria. She had received deceased donor kidney transplantation 8 years earlier, but developed graft failure due to a recurrence of immunoglobulin A nephropathy. Laboratory tests revealed anemia and elevated levels of inflammatory markers. Enhanced abdominopelvic computed tomography showed graft swelling with perirenal fat stranding. Thus, we administered antibiotics for a urinary tract infection and increased the doses of steroids due to suspicion of graft intolerance syndrome. However, the patient's symptoms gradually worsened. Eventually, we performed graft nephrectomy and histologically confirmed EBV-positive diffuse large B cell lymphoma. We report a case in which a PTLD was considered in the differential diagnosis of a kidney transplant recipient with symptoms similar to those of a urinary tract infection or graft intolerance syndrome.
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Affiliation(s)
- Ji Hyun Yeom
- Department of Internal Medicine, Jeonbuk National University Hospital, Jeonju, Korea
- Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
| | - Won Kim
- Department of Internal Medicine, Jeonbuk National University Hospital, Jeonju, Korea
- Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine of Jeonbuk National University, Jeonju, Korea
| | - Kyung Pyo Kang
- Department of Internal Medicine, Jeonbuk National University Hospital, Jeonju, Korea
- Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine of Jeonbuk National University, Jeonju, Korea
| | - Hyeongwan Kim
- Department of Internal Medicine, Jeonbuk National University Hospital, Jeonju, Korea
- Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
| | - Hee Chul Yu
- Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine of Jeonbuk National University, Jeonju, Korea
- Department of Surgery, Jeonbuk National University Hospital, Jeonju, Korea
| | - Hong Pil Hwang
- Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine of Jeonbuk National University, Jeonju, Korea
- Department of Surgery, Jeonbuk National University Hospital, Jeonju, Korea
| | - Byeoung Hoon Chung
- Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine of Jeonbuk National University, Jeonju, Korea
- Department of Surgery, Jeonbuk National University Hospital, Jeonju, Korea
| | - Kyu Yun Jang
- Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
- Department of Pathology, Jeonbuk National University Medical School, Jeonju, Korea
| | - Sik Lee
- Department of Internal Medicine, Jeonbuk National University Hospital, Jeonju, Korea
- Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine of Jeonbuk National University, Jeonju, Korea
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Hassan S, Mumford L, Robinson S, Foukanelli D, Torpey N, Ploeg RJ, Mamode N, Murphy MF, Brown C, Roberts DJ, Regan F, Willicombe M. Blood transfusions post kidney transplantation are associated with inferior allograft and patient survival-it is time for rigorous patient blood management. FRONTIERS IN NEPHROLOGY 2023; 3:1236520. [PMID: 37675353 PMCID: PMC10479650 DOI: 10.3389/fneph.2023.1236520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/03/2023] [Indexed: 09/08/2023]
Abstract
Background Patient Blood Management (PBM), endorsed by the World Health Organisation is an evidence-based, multi-disciplinary approach to minimise inappropriate blood product transfusions. Kidney transplantation presents a particular challenge to PBM, as comprehensive evidence of the risk of transfusion is lacking. The aim of this study is to investigate the prevalence of post-transplant blood transfusions across multiple centres, to analyse risk factors for transfusion and to compare transplant outcomes by transfusion status. Methods This analysis was co-ordinated via the UK Transplant Registry within NHS Blood and Transplant (NHSBT), and was performed across 4 centres. Patients who had received a kidney transplant over a 1-year period, had their transfusion status identified and linked to data held within the national registry. Results Of 720 patients, 221(30.7%) were transfused, with 214(29.7%) receiving a red blood cell (RBC) transfusion. The proportion of patients transfused at each centre ranged from 20% to 35%, with a median time to transfusion of 4 (IQR:0-12) days post-transplant. On multivariate analysis, age [OR: 1.02(1.01-1.03), p=0.001], gender [OR: 2.11(1.50-2.98), p<0.0001], ethnicity [OR: 1.28(1.28-2.60), p=0.0008], and dialysis dependence pre-transplant [OR: 1.67(1.08-2.68), p=0.02], were associated with transfusion. A risk-adjusted Cox proportional hazards model showed transfusion was associated with inferior 1-year patient survival [HR 7.94(2.08-30.27), p=0.002] and allograft survival [HR: 3.33(1.65-6.71), p=0.0008], and inferior allograft function. Conclusion RBC transfusions are common and are independently associated with inferior transplant outcomes. We urge that further research is needed to understand the mechanisms behind the outcomes, to support the urgent development of transplant-specific anaemia guidelines.
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Affiliation(s)
- Sevda Hassan
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Imperial College Renal and Transplant Centre, Imperial College Healthcare National Health Service (NHS) Trust, Hammersmith Hospital, London, United Kingdom
| | - Lisa Mumford
- Statistics and Clinical Studies, National Health Service (NHS) Blood and Transplant, Bristol, United Kingdom
| | - Susan Robinson
- Department of Haematology, Guys, Evelina and St Thomas National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Dora Foukanelli
- Department of Haematology, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Nick Torpey
- Department of Clinical Nephrology and Transplantation, Cambridge University Hospitals National Health Service (NHS) Foundation Trust, Cambridge, United Kingdom
| | - Rutger J. Ploeg
- Department of Surgery, Nuffield Department of Surgical Science, University of Oxford, Oxford, United Kingdom
| | - Nizam Mamode
- Department of Transplantation, Guys, Evelina and St Thomas National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Michael F. Murphy
- National Health Service (NHS) Blood and Transplant, and Nuffield Department of Clinical and Laboratory Sciences, University of Oxford, Oxford, United Kingdom
| | - Colin Brown
- Haematology, National Health Service (NHS) Blood and Transplant, London, United Kingdom
| | - David J. Roberts
- Haematology, National Health Service (NHS) Blood and Transplant, London, United Kingdom
| | - Fiona Regan
- Haematology, National Health Service (NHS) Blood and Transplant, London, United Kingdom
| | - Michelle Willicombe
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Imperial College Renal and Transplant Centre, Imperial College Healthcare National Health Service (NHS) Trust, Hammersmith Hospital, London, United Kingdom
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Baradaran H, Hashem Zadeh A, Dashti-Khavidaki S, Laki B. Management of drug-induced neutropenia, thrombocytopenia, and anaemia after solid organ transplantation: A comprehensive review. J Clin Pharm Ther 2022; 47:1895-1912. [PMID: 36250775 DOI: 10.1111/jcpt.13775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Hananeh Baradaran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Simin Dashti-Khavidaki
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahareh Laki
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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Bugge TB, Perch M, Rezahosseini O, Crone CG, Jensen K, Schultz HH, Bredahl P, Hornum M, Nielsen SD, Lund TK. Post-Transplantation Anemia and Risk of Death Following Lung Transplantation. Transplant Proc 2022; 54:2329-2336. [PMID: 36127173 DOI: 10.1016/j.transproceed.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/23/2022] [Accepted: 07/14/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Post-transplantation anemia (PTA) is frequent among solid organ transplant recipients and has been associated with increased morbidity and mortality. However, the prevalence and impact of PTA in lung transplant recipients is still not elucidated. METHODS We performed a retrospective cohort study of adult Danish lung transplant recipients between January 2010 and December 2019. The prevalence and severity of PTA were determined during the first three years post-transplantation. Associations between PTA and selected risk factors were established using uni- and multivariate logistic regression models. RESULTS A total of 278 patients were included. At one and three years post-lung transplantation the prevalence of PTA was 75% and 52%, respectively. Male sex was associated with increased odds of PTA at all time points (aOR ranging from 2.3, 95% CI 1.1-4.6, P = 0.02 to 5.9, 95% CI 2.6-14, P < .001). Cystic fibrosis was also associated with anemia at one-year post-transplantation (aOR 4.3, 95% CI 1.2-17, P = 0.03). We found no strong associations between PTA and renal function or viral infections. Excess mortality in recipients with moderate or severe anemia compared to patients with mild or no anemia was borderline statistically significant at one-year post-lung transplantation (aHR 2.0, 95% CI 0.9-4.4, P = 0.07). DISCUSSION Post-transplantation anemia is very common in Danish lung transplant recipients. Male sex and cystic fibrosis are independent risk factors for development of anemia. Further investigation on PTA, the underlying mechanisms, and its clinical impact is needed.
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Affiliation(s)
- Terese Brun Bugge
- Department of Cardiology, Section for Lung Transplantation, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark.
| | - Michael Perch
- Department of Cardiology, Section for Lung Transplantation, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Nephrology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Omid Rezahosseini
- Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | | | - Kristine Jensen
- Department of Cardiology, Section for Lung Transplantation, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Hans Henrik Schultz
- Department of Cardiology, Section for Lung Transplantation, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Pia Bredahl
- Department of Thoracic Anesthesia, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Mads Hornum
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Thoracic Anesthesia, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark; Department of Nephrology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Susanne Dam Nielsen
- Department of Infectious Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Thomas Kromann Lund
- Department of Cardiology, Section for Lung Transplantation, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
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10
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Tariq H, Dobre M. Metabolic acidosis post kidney transplantation. Front Physiol 2022; 13:989816. [PMID: 36082221 PMCID: PMC9445136 DOI: 10.3389/fphys.2022.989816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/01/2022] [Indexed: 11/23/2022] Open
Abstract
Metabolic acidosis, a common complication in patients with chronic kidney disease (CKD), results in a multitude of deleterious effects. Though the restoration of kidney function following transplantation is generally accompanied by a correction of metabolic acidosis, a subset of transplant recipients remains afflicted by this ailment and its subsequent morbidities. The vulnerability of kidney allografts to metabolic acidosis can be attributed to reasons similar to pathogenesis of acidosis in non-transplant CKD, and to transplant specific causes, including donor related, recipient related, immune mediated factors, and immunosuppressive medications. Correction of metabolic acidosis in kidney transplantation either with alkali therapy or through dietary manipulations may have potential benefits and the results of such clinical trials are eagerly awaited. This review summarizes the published evidence on the pathogenesis and clinical consequences of chronic metabolic acidosis in kidney transplant recipients.
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Affiliation(s)
- Hafsa Tariq
- Division of Nephrology, University of Rochester Medical Center, Rochester, NY, United States
| | - Mirela Dobre
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, United States
- *Correspondence: Mirela Dobre,
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11
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Alshamsi I. Extended Literature Review of the role of erythropoietin stimulating agents (ESA) use in the management of post renal transplant anaemia. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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12
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Kouri A, Balani S, Kizilbash S. Anemia in Pediatric Kidney Transplant Recipients-Etiologies and Management. Front Pediatr 2022; 10:929504. [PMID: 35795334 PMCID: PMC9251011 DOI: 10.3389/fped.2022.929504] [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] [Received: 04/26/2022] [Accepted: 05/26/2022] [Indexed: 11/21/2022] Open
Abstract
Posttransplant anemia (PTA) is a common complication of pediatric kidney transplantation, with a prevalence ranging from 22 to 85%. PTA is categorized as early (within 6 months posttransplant) and late (>6 months posttransplant). Early PTA is typically associated with surgical blood losses and iron deficiency. Late PTA primarily results from graft dysfunction; however, iron deficiency, drug toxicity, and posttransplant inflammation also play a role. PTA is more severe compared with the anemia in glomerular-filtration-rate matched patients with native chronic kidney disease. Treatment of PTA is directed toward the underlying cause. Erythropoiesis stimulating agents (ESA) are effective; however, their use is limited in the transplant setting. Timely diagnosis and treatment of PTA are vital to prevent long-term adverse outcomes in pediatric transplant recipients.
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Affiliation(s)
- Anne Kouri
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
| | - Shanthi Balani
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
| | - Sarah Kizilbash
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
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Ujjawal A, Schreiber B, Verma A. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) in kidney transplant recipients: what is the evidence? Ther Adv Endocrinol Metab 2022; 13:20420188221090001. [PMID: 35450095 PMCID: PMC9016587 DOI: 10.1177/20420188221090001] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/04/2022] [Indexed: 12/15/2022] Open
Abstract
Several recent randomized controlled trials (RCTs) have demonstrated the wide clinical application of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in improving kidney and cardiovascular outcomes in patients with native kidney disease. In April 2021, Dapagliflozin became the first SGLT2 inhibitor to be approved by the Food and Drug Administration (FDA) for the treatment of chronic kidney disease (CKD) regardless of diabetic status. However, while these agents have drawn much acclaim for their cardiovascular and nephroprotective effects among patients with native kidney disease, little is known about the safety and efficacy of SGLT2i in the kidney transplant setting. Many of the mechanisms by which SGLT2i exert their benefit stand to prove equally as efficacious or more so among kidney transplant recipients as they have in patients with CKD. However, safety concerns have excluded transplant recipients from all large RCTs, and clinicians and patients alike are left to wonder if the benefits of these amazing drugs outweigh the risks. In this review, we will discuss the known mechanisms SGLT2i exploit to provide their beneficial effects, the potential benefits, and risks of these agents in the context of kidney transplantation, and finally, we will discuss current findings of the published literature for SGLT2i use in kidney transplant recipients and propose potential directions for future research.
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Loutradis C, Sarafidis P, Marinaki S, Berry M, Borrows R, Sharif A, Ferro CJ. Role of hypertension in kidney transplant recipients. J Hum Hypertens 2021; 35:958-969. [PMID: 33947943 DOI: 10.1038/s41371-021-00540-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/24/2021] [Accepted: 04/09/2021] [Indexed: 02/03/2023]
Abstract
Cardiovascular events are one of the leading causes of mortality in kidney transplant recipients. Hypertension is the most common comorbidity accompanying chronic kidney disease, with prevalence remaining as high as 90% even after kidney transplantation. It is often poorly controlled. Abnormal blood pressure profiles, such as masked or white-coat hypertension, are also extremely common in these patients. The pathophysiology of blood pressure elevation in kidney transplant recipients is complex and includes transplantation-specific risk factors, which are added to the traditional or chronic kidney disease-related factors. Despite these observations, hypertension management has been an under-researched area in kidney transplantation. Thus, relevant evidence derives either from studies in the general population or from small trials in kidney transplant recipients. Based on the relevant guidelines in the general population, lifestyle modifications should probably be applied as the first step of hypertension management in kidney transplant recipients. The optimal pharmacological management of hypertension in kidney transplant recipients is also not clear. Dihydropyridine calcium channel blockers are commonly used as first line agents because of their lack of adverse effects on the kidney, while other antihypertensive drug classes are under-utilised due to fear of the possible haemodynamic consequences on renal function. This review summarizes the existing data on the pathophysiology, diagnosis, prognostic significance and management of hypertension in kidney transplantation.
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Affiliation(s)
- Charalampos Loutradis
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK.,Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Smaragdi Marinaki
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens, Greece
| | - Miriam Berry
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
| | - Richard Borrows
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
| | - Adnan Sharif
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK. .,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.
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The Association between Peri-Transplant RBC Transfusion and Graft Failure after Kidney Transplantation: A Nationwide Cohort Study. J Clin Med 2021; 10:jcm10163750. [PMID: 34442041 PMCID: PMC8397181 DOI: 10.3390/jcm10163750] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/30/2021] [Accepted: 08/18/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Patients undergoing kidney transplantation (KT) often receive red blood cell (RBC) transfusion during admission for KT which may increase the risk of allosensitization. The association between peri-transplant RBC transfusion and graft survival was evaluated using a nationwide cohort. Methods: This retrospective study analyzed 13,871 patients who underwent KT in Korea between 2007 and 2015. The outcomes were graft failure rate and overall patient survival depending on the amount of RBC transfusion. Results: The overall graft failure rate was 15.5%. Compared to the graft failure rate of 13.5% in the no transfusion group, the graft failure rate was 15.4% in the 1–2 units group (sHR 1.06 (95% CI 0.97–1.17), p = 0.216), 21.4% in the 3–5 units group (sHR 1.39 (1.21–1.61), p < 0.001), and 35.3% in the 6 or more units group (sHR 2.20 (1.70–2.85), p < 0.001). The overall survival rate was 97.5% in the no transfusion group, compared to 95.9% in the 1–2 units group (HR 1.50 (1.22–1.83), p < 0.001), 92.0% in the 3–5 units group (HR 2.43 (1.87–3.15), p < 0.001), and 67.5% in the 6 or more units group (HR 6.81 (5.03–9.22), p < 0.001). Conclusions: Peri-transplant RBC transfusion was independently associated with the increased risk of renal allograft failure and death in KT patients.
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Abstract
Uterine transplantation (UTx) is a fertility restoring treatment for women with absolute uterine factor infertility. At a time when there is no question of the procedure's feasibility, and as the number of livebirths begins to increase exponentially, various important reproductive, fetal, and maternal medicine implications have emerged. Detailed outcomes from 17 livebirths following UTx are now available, which are reviewed herein, along with contextualized extrapolation from pregnancy outcomes in other solid organ transplants. Differences in recipient demographics and reproductive aspirations between UTx and other transplant recipients make extrapolating management strategies and outcomes in other solid organ transplants inappropriate. Whereas preterm delivery remains prominent, small for gestational age or hypertensive disorders do not appear to be as prevalent following UTx when compared to other solid organ transplants. Given the primary objective of undertaking UTx is to achieve a livebirth, publication of reproductive outcomes is essential at this early stage, to reflect on and optimize the management of future cases.
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Kallapur A, Jang C, Yin O, Mei JY, Afshar Y. Pregnancy care in solid organ transplant recipients. Int J Gynaecol Obstet 2021; 157:502-513. [PMID: 34245162 DOI: 10.1002/ijgo.13819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/28/2021] [Accepted: 07/08/2021] [Indexed: 12/12/2022]
Abstract
Recipients of solid organ transplants who become pregnant represent an obstetrically high-risk population. Preconception planning and effective contraception tailored to the individual patient are critical in this group. Planned pregnancies improve both maternal and neonatal outcomes and provide a window of opportunity to mitigate risk and improve lifelong health. Optimal management of these pregnancies is not well defined. Common pregnancy complications after transplantation include hypertension, preterm birth, infection, and metabolic disease. Multidisciplinary preconception and prepartum management, and counseling decrease complications and benefit the maternal-neonatal dyad.
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Affiliation(s)
- Aneesh Kallapur
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Christine Jang
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Ophelia Yin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Jenny Y Mei
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Raichoudhury R, Spinowitz BS. Treatment of anemia in difficult-to-manage patients with chronic kidney disease. Kidney Int Suppl (2011) 2021; 11:26-34. [PMID: 33777493 DOI: 10.1016/j.kisu.2020.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/17/2020] [Accepted: 12/29/2020] [Indexed: 12/14/2022] Open
Abstract
The management of anemia of chronic kidney disease (CKD) is often challenging. In particular, for patients with underlying inflammation, comorbid type 2 diabetes or cancer, those hospitalized, and recipients of a kidney transplant, the management of anemia may be suboptimal. Responsiveness to iron and/or erythropoiesis-stimulating agents, the mainstay of current therapy, may be reduced and the risk of adverse reactions to treatment is increased in these difficult-to-manage patients with anemia of CKD. This review discusses the unique patient and disease characteristics leading to complications and suboptimal treatment response. New treatment options in clinical development, such as hypoxia-inducible factor-prolyl hydroxylase (HIF-PH) inhibitors, may be particularly useful for difficult-to-treat patients. In clinical studies, HIF-PH inhibitors provided increased hemoglobin levels and improved iron utilization in anemic patients with non-dialysis-dependent and dialysis-dependent CKD, and preliminary data suggest that HIF-PH inhibitors may be equally effective in patients with or without underlying inflammation. The availability of new treatment options, including HIF-PH inhibitors, may improve treatment outcomes in difficult-to-manage patients with anemia of CKD.
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Affiliation(s)
- Ritesh Raichoudhury
- Division of Nephrology, Department of Medicine, NewYork-Presbyterian Queens, New York, New York, USA
| | - Bruce S Spinowitz
- Division of Nephrology, Department of Medicine, NewYork-Presbyterian Queens, New York, New York, USA
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[Persistent anemia after kidney transplantation in a 36-year-old male patient-an unusual cause]. Internist (Berl) 2020; 62:320-325. [PMID: 33244626 DOI: 10.1007/s00108-020-00909-7] [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: 10/22/2022]
Abstract
An allogeneic kidney transplantation (match 1‑1‑0, cytomegalovirus, CMV, donor, D, +/recipient, R, - high risk) was performed in a 36-year-old patient. The patient was on dialysis due to a tubulointerstitial nephritis confirmed by biopsy 11 years previously. Posttransplantation there was a gradual decrease in the hemoglobin (Hb) level from 11.4 g/dl to 7.3 g/dl during the initial hospitalization period. Initially this was explained by the kidney transplantation and chronic fibrosing antral gastritis with erosions. Despite repeated transfusion of red cell concentrates, a refractory anemia persisted, which is why the patient presented several times at our clinic for further diagnosis and treatment. The presence of giant erythroblasts in the bone marrow and quantitative detection of parvovirus B19 (>900 million IU/ml DNA replications) was consistent with a virus-associated red cell aplasia. Intravenous immunoglobulin administration was established and showed long-term therapeutic success.
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Steuer LV, Kondo AT, Cipolletta AN, Sakashita AM, Hamerschlak N, Kutner JM. Predictive factors for the development of anemia after hematopoietic stem cell donation. Transfusion 2020; 61:159-166. [PMID: 33052621 DOI: 10.1111/trf.16124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/29/2020] [Accepted: 08/31/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although Hematopoietic Stem Cells (HSC) donation through bone marrow (BM) and peripheral blood (PB) are usually safe procedures, adverse events are expected. One of the most common events especially among BM donors (BMD) is the development of anemia. To protect the BMD and preserve the hemoglobin levels, many centers collect autologous pre-procedure blood, but the actual benefits of this procedure is controversial. METHODS AND MATERIALS This study analyzed retrospectively data to observe what factors may influence the occurrence of post-donation anemia and also evaluate the relevance of autologous red blood cell pre procedure donation (PAD). RESULTS The development of immediately post donation anemia (IP) was higher in BMD than in PB donors (64.2% BMD and 10.7% PBD, P < .001) and also in late post donation (LP) (28.4% BMD and 3.6% PBD, P = .007). The study demonstrated an association between PAD and anemia in IP (72.7% with anemia and 27.3% without anemia, P = .006) and an association between the volume of red blood cells in the donated hematopoietic product and the development of anemia in LP (356.3 mL and 297.8 mL, P = .037). CONCLUSION In conclusion, collection of HSC through BM is a risk factor for anemia and PAD is a risk factor for IP anemia.
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Affiliation(s)
- Lia V Steuer
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Andrea T Kondo
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Andrea N Cipolletta
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Araci M Sakashita
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Nelson Hamerschlak
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - José M Kutner
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Parvovirus Infection-Related Anemia after Kidney Transplantation. Case Rep Transplant 2020; 2020:6437392. [PMID: 32082691 PMCID: PMC7013336 DOI: 10.1155/2020/6437392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/07/2020] [Accepted: 01/20/2020] [Indexed: 11/17/2022] Open
Abstract
Anemia postkidney transplantation is an important issue which has been correlated with increased hospitalizations and higher mortality. Infections, including those due to parvovirus B19, CMV, and BK virus (polyomavirus), have also been associated with an increased risk of anemia. Here, we present a case of new-onset anemia in a kidney transplant recipient within 3 months of transplant. The patient was found to have multiple viral infections from parvo B19, BK virus, and rhinovirus. The anemia resolved completely after successful reduction in the parvo B19 and BK viral load. Workup for viral infections must be considered in the differential diagnosis of postkidney transplant anemia.
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Deceased donor kidney transplant complicated by spontaneous rupture of native kidney in a HIV patient. CEN Case Rep 2020; 9:182-185. [PMID: 31989454 DOI: 10.1007/s13730-020-00453-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 01/18/2020] [Indexed: 10/25/2022] Open
Abstract
Spontaneous native kidney rupture (SNKR) is a rare occurrence, commonly associated with underlying renal tumors or acquired renal cystic disease in both the kidney transplant (KT) and non-KT populations. Herein, we present a 65-year-old African American man who experienced a non-malignant SNKR 6 days after a deceased donor KT and underwent emergent native nephrectomy. The patient's hospital course was complicated by thrombocytopenia and refractory hypertension. He experienced delayed graft function and was maintained on hemodialysis until post-operative day 30. This case demonstrates an unusual presentation of SNKR in the immediate post-KT setting and illustrates the clinical decision-making algorithm.
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Abstract
Advancement in kidney transplantation has led to prolonged survival in our population with kidney disease. Newer agents of immunosuppression have made this possible with less rejections and lesser opportunistic infections and transplant related deaths. Preventative care like timely vaccines, cancer screenings, aggressive blood pressure, blood sugar, lipid control, timely referral to consultants is required in these patient population to provide quality care and to prolong their survival. Primary care physicians are the best advocate for our transplant populations. To care for these complex transplant patients, it is vital for primary care physicians to be familiar with the overall approach on our patients.
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Affiliation(s)
- Kavitha Ramaswamy
- Thomas Jefferson University Hospital, Division of Nephrology, 833 Chestnut St, Suite 700, Philadelphia, PA 19107, USA.
| | - Hector M Madariaga
- Good Samaritan Medical Center, Department of Medicine, 235N Pearl St, Brockton, MA 02301, USA
| | - Beje S Thomas
- Georgetown University Medical Center, MedStar Georgetown Transplant Institute, 3800 Reservoir Road, Washington, DC 20007 USA
| | - Edgar V Lerma
- University of Illinois at Chicago College of Medicine/ Advocate Christ Medical Center, Oak Lawn, IL, USA
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Okumi M, Okabe Y, Unagami K, Kakuta Y, Iizuka J, Takagi T, Shirakawa H, Shimizu T, Omoto K, Ishida H, Nakamura M, Tanabe K. The interaction between post-transplant anemia and allograft function in kidney transplantation: The Japan Academic Consortium of Kidney Transplantation-II study. Clin Exp Nephrol 2019; 23:1066-1075. [PMID: 31020441 DOI: 10.1007/s10157-019-01737-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 04/09/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND The interaction between post-transplant anemia (PTA) and allograft function in kidney transplantation has not been evaluated directly. PTA, defined by WHO/AST criteria, was investigated in 1307 adult kidney transplant recipients between 2000 and 2015 (median follow-up, 7 years). METHODS We investigated the impact of hemoglobin (Hb) on graft failure (non-censored for death) and their interactions, time-dependent Cox model, and subgroup analysis were used. RESULTS PTA prevalence was 43.6% at 7 years and varied according to allograft function, recipient sex, and follow-up period. Decreased Hb considering the time-varying effect was associated with an increased risk of graft failure (hazard ratio = 1.83, 95% CI 1.66-2.02, P < 0.001). In subgroup analysis, allograft function (post-transplant time-averaged estimated glomerular filtration rate and cut point: 45 mL/min/1.73 m2) had significant interaction (P = 0.032). The 7-year graft failure rate in recipients with PTA and high eGFR was 7.7% (HR 1.52, 95% CI 1.25-1.84), whereas in those with PTA and low eGFR was 19.9% (HR 2.00, 95% CI 1.74-2.31). CONCLUSIONS The unfavorable impact of PTA was significantly enhanced by low allograft function. PTA is likely to be associated with graft failure due to interaction with allograft function. Therefore, we should consider both Hb level and allograft function while determining the treatment strategy.
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Affiliation(s)
- Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan.
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kohei Unagami
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoichi Kakuta
- Department of Urology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| | - Junpei Iizuka
- Department of Urology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| | - Toshio Takagi
- Department of Urology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| | | | - Tomokazu Shimizu
- Department of Urology, Toda Chuo General Hospital, Saitama, Japan
| | - Kazuya Omoto
- Department of Urology, Toda Chuo General Hospital, Saitama, Japan
| | - Hideki Ishida
- Department of Organ Transplant Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
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Parvovirus B19 Induced Red Cell Aplasia in a Heart Transplant Patient Diagnosed on Pleural Fluid. Transplantation 2018; 102:e367-e368. [DOI: 10.1097/tp.0000000000002277] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Parodis López Y, Santana Estupiñán R, Marrero Robayna S, Gallego Samper R, Henríquez Palop F, Rivero Vera JC, Camacho Galán R, Pena López MJ, Sablón González N, González Cabrera F, Oliva Dámaso E, Vega Díaz N, Rodríguez Pérez JC. Anaemia and fever in Kidney transplant. The role of human parvovirus B19. Nefrologia 2016; 37:206-212. [PMID: 27865549 DOI: 10.1016/j.nefro.2016.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Revised: 05/27/2016] [Accepted: 08/25/2016] [Indexed: 11/17/2022] Open
Abstract
Infections remain an issue of particular relevance in renal transplant patients, particularly viral infections. Human parvovirus B19 infection causes severe refractory anaemia, pancytopenia and thrombotic microangiopathy. Its presence is recognized by analysing blood polymerase chain reaction (PCR) and by the discovery of typical giant proerythroblasts in the bone marrow. We report the case of a 65 year-old man with a history of deceased donor renal transplant in September 2014. At 38 days after the transplant, the patient presented progressive anaemia that was resistant to erythropoiesis-stimulating agents. At 64 days after transplant, hyperthermia occurred with progressive deterioration of the patient's general condition. The viral serology and the first blood PCR for human parvovirus B19 were both negative. At 4 months and 19 days after, a bone marrow biopsy was conducted, showing giant erythroblasts with nuclear viral inclusions that were compatible with parvovirus; a PCR in the tissue confirmed the diagnosis. A second blood PCR was positive for parvovirus. After treatment with intravenous immunoglobulin and the temporary discontinuation of mycophenolate mofetil, a complete remission of the disease occurred, although the blood PCR for parvovirus B19 remained positive, so monitoring is necessary for future likely recurrence.
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Affiliation(s)
- Yanet Parodis López
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, España
| | - Raquel Santana Estupiñán
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, España
| | - Silvia Marrero Robayna
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, España
| | - Roberto Gallego Samper
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, España
| | - Fernando Henríquez Palop
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, España
| | - José Carlos Rivero Vera
- Servicio de Anatomía Patológica, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, España
| | - Rafael Camacho Galán
- Servicio de Anatomía Patológica, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, España
| | - María José Pena López
- Servicio de Microbiología, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, España
| | - Nery Sablón González
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, España
| | - Fayna González Cabrera
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, España
| | - Elena Oliva Dámaso
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, España
| | - Nicanor Vega Díaz
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, España
| | - José Carlos Rodríguez Pérez
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, España.
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Krause I, Davidovits M, Tamary H, Yutcis M, Dagan A. Anemia and markers of erythropoiesis in pediatric kidney transplant recipients compared to children with chronic renal failure. Pediatr Transplant 2016; 20:958-962. [PMID: 27620552 DOI: 10.1111/petr.12792] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2016] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Irit Krause
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel. .,Department of Pediatrics C, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel. .,Sackler Faculty of Medicine Tel Aviv University, Ramat Aviv, Israel.
| | - Miriam Davidovits
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel.,Sackler Faculty of Medicine Tel Aviv University, Ramat Aviv, Israel
| | - Hannah Tamary
- Sackler Faculty of Medicine Tel Aviv University, Ramat Aviv, Israel.,Pediatric Hematology Unit, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel
| | - Maria Yutcis
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel
| | - Amit Dagan
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel.,Sackler Faculty of Medicine Tel Aviv University, Ramat Aviv, Israel
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Medical management of chronic kidney disease in the renal transplant recipient. Curr Opin Nephrol Hypertens 2016; 24:587-93. [PMID: 26371526 DOI: 10.1097/mnh.0000000000000166] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW An updated overview of the state-of-the-art approaches to the care of chronic kidney disease-related issues in renal transplant recipients. RECENT FINDINGS These include the impact of immunosuppression therapy on kidney function, the management of cardiovascular risk, metabolic bone disease, and hematologic complications, with a focus on the care of the patient with a failing allograft. SUMMARY A kidney transplant improves patient morbidity and mortality, but almost all transplant patients continue to have morbidity related to chronic kidney disease. It is increasingly clear that the provision of adequate immunosuppression is important to preserve allograft function. Recent studies have lent support to current guidelines for the management of cardiovascular risk factors in transplant patients. New data regarding the management of metabolic bone disease are sparse. Erythropoietin replacement may improve outcomes in transplant recipients, but the optimal target hemoglobin level is not known. Cessation of immunosuppression in the failed allograft carries the risk of rejection and allosensitization. New evidence suggests that nephrectomy may reduce mortality in patients with a failed allograft, but likely enhances sensitization in the patient awaiting retransplantation.
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Montada-Atin T, Choi D, Woo M, Retnakaran R, Huang M, Prasad GVR, Zaltzman JS. Reduction in new-onset diabetes mellitus after renal transplant with erythropoietin-stimulating agents: a retrospective cohort study. Can J Kidney Health Dis 2016; 3:23. [PMID: 27119016 PMCID: PMC4845385 DOI: 10.1186/s40697-016-0114-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 04/05/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Studies have shown that erythropoietin-stimulating agents (ESAs) protect mice against the development of diabetes through direct effects on pancreatic ß cells. However, the effect of ESAs on the incidence of diabetes in humans has not been well studied. It is unknown whether exposure to ESAs is associated with a reduced incidence of new-onset diabetes after transplant (NODAT). OBJECTIVE The objective of this study is to examine the relationship between ESA exposure post-renal transplant and the development of NODAT. DESIGN We performed a single center, retrospective cohort analysis. PATIENTS We compared patients who received a first live or deceased donor renal allograft, with any exposure to an ESA vs. those without such exposure and who developed NODAT and who did not. Patients with a prior history of diabetes mellitus or multi-organ transplant, including a second renal transplant were excluded. MEASUREMENTS AND METHODS NODAT was defined based on the 2008 Canadian Diabetes Association criteria. Multivariate logistic regression analysis was performed to determine factors independently associated with NODAT. RESULTS One hundred thirty-two (29 %) patients were exposed to an ESA, four of which developed NODAT compared to 128 who did not develop NODAT (p < 0.0001). Of those not exposed to an ESA, 15 % (48/319) developed NODAT. By Fisher's exact test, exposure to an ESA at any time post-transplant reduced the risk of developing NODAT; odds ratio (OR) = 0.08, 95 % confidence interval (CI) (0.018-0.352), p = 0.0008. Older age; OR = 1.41, 95 % CI (1.036-1.933), p < 0.02, higher random blood sugar at discharge; OR = 1.30, 95 % CI (1.077-1.57), p < 0.006 and deceased donor; OR 2.18 CI (1.009-4.729), p = 0.04 were associated with an increased risk of NODAT. LIMITATIONS The limitations of this study include its retrospective nature, single center, and homogenous population; thus, generalizability of the results must be approached with caution. CONCLUSION ESA exposure may be associated with a reduced incidence of NODAT in the post-renal transplant population. The role of ESA in preventing NODAT requires further investigation.
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Affiliation(s)
- Tess Montada-Atin
- />Renal Transplant Program, St. Michael’s Hospital, 61 Queen Street East, 9th Floor, Toronto, ON Canada M5C 2T2
- />Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Diana Choi
- />Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Minna Woo
- />Endocrinology and Metabolism, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, ON Canada M5G 2C4
- />Division of Endocrinology, University of Toronto, Toronto, Canada
- />Department of Medicine and Biophysics, University of Toronto, Toronto, Canada
| | - Ravi Retnakaran
- />Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, 60 Murray Street, Toronto, ON Canada M5T 3L9
- />Department of Medicine, University of Toronto, Toronto, Canada
- />Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
| | - Michael Huang
- />Renal Transplant Research, St. Michael’s Hospital, 30 Bond Street, Toronto, ON Canada M5B 1W8
| | - G. V. Ramesh Prasad
- />Renal Transplant Program, St. Michael’s Hospital, 61 Queen Street East, 9th Floor, Toronto, ON Canada M5C 2T2
- />Division of Nephrology, University of Toronto, Toronto, Canada
| | - Jeffrey S. Zaltzman
- />Renal Transplant Program, St. Michael’s Hospital, 61 Queen Street East, 9th Floor, Toronto, ON Canada M5C 2T2
- />Department of Medicine, University of Toronto, Toronto, Canada
- />Division of Nephrology, University of Toronto, Toronto, Canada
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Ruiz-Fuentes MDC, Pérez-Marfil A, Ruiz-Fuentes N, De Gracia-Guindo C, Osuna-Ortega A. Treatment With Darbepoetin During the First Year After Renal Transplantation: The Starting Point. Transplant Proc 2015; 47:2622-5. [PMID: 26680053 DOI: 10.1016/j.transproceed.2015.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 09/25/2015] [Accepted: 10/06/2015] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Multiple factors are associated with post-transplantation anemia, and renal function is the main factor. The aims of this study were to compare the evolution of hemoglobin in the first year post-transplantation according to darbepoetin (DA) treatment, and factors related to it, to evaluate the difference between earlier versus delayed treatment, and to describe the dose change pattern. PATIENTS AND METHODS We describe a retrospective study of cohorts in 462 transplant recipients (2004-2011). The variables reported were from donor, transplantation recipient, and DA treatment. RESULTS In this study, 67.5% of patients were treated with DA, 32.5% were not. The comparison of hemoglobin in both groups during the first year showed a similar evolution with significant differences between consecutive measures until the second trimester. The hemoglobin of the treated group was significantly lower. The evolution of renal function was not different. Multivariate analysis related DA treatment to delayed graft function (DGF) and albuminuria in the first year. Patients with early versus delayed DA introduction did not show a difference regarding length of treatment, but the total dose in the delayed introduction was lower. The evolution of creatinine and hemoglobin was similar in both groups. CONCLUSION The introduction of DA was related to DGF and albuminuria. The delayed introduction of DA meant the following: less total dose than earlier introduction, no difference in length of treatment, and a similar evolution in hemoglobin and renal function in both groups. The lack of guidelines about DA treatment in renal transplantation makes it difficult to establish a pattern of dose adjustment.
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Affiliation(s)
| | - A Pérez-Marfil
- Nephrology Department, University Hospital of Granada, Granada, Spain
| | - N Ruiz-Fuentes
- Statistics and Operations Research Department, University of Jaén, Jaén, Spain
| | | | - A Osuna-Ortega
- Nephrology Department, University Hospital of Granada, Granada, Spain
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Kalantzi M, Kalliakmani P, Papachristou E, Papasotiriou M, Savvidaki E, Zavvos V, Karavias D, Goumenos DS, Vlachojannis JG. Parameters influencing blood erythropoietin levels of renal transplant recipients during the early post-transplantation period. Transplant Proc 2014; 46:3179-82. [PMID: 25420853 DOI: 10.1016/j.transproceed.2014.10.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AIM Renal transplantation is accompanied by restoration of renal function and endogenous erythropoietin production. The purpose of this study was to investigate the time-related changes of endogenous erythropoietin secretion in the early renal post-transplant period and the influence of various parameters to this process. METHODS Fifty-eight patients were enrolled in the study and followed up for 3 months after successful renal transplantation. Erythropoietin levels were measured at regular intervals and correlated with renal function, cold ischemia time and immunosuppressive regimen used. RESULTS Two peaks of serum erythropoietin levels were observed: an early peak that occurred within two days after transplantation and a late one, between weeks 2 and 4, which resulted in increased blood hemoglobin levels. Factors that were found to correlate with erythropoietin levels were delayed graft function, cyclosporine use and prolonged cold ischemia time. Serum creatinine did not correlate to erythropoietin levels although the reduction of serum creatinine preceded the rise of erythropoietin levels. Normal hemoglobin values were restored about three months after successful renal transplantation. CONCLUSION Serum erythropoietin levels increase during the early post-transplantation period resulting in correction of anemia three months after a successful renal transplantation. Restoration of allograft function is a prerequisite for erythropoietin secretion, while cold ischemia time and immunosuppressive regimen affect graft function.
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Affiliation(s)
- M Kalantzi
- University Hospital of Patras, Transplantation Center, Patras, Greece
| | - P Kalliakmani
- University Hospital of Patras, Transplantation Center, Patras, Greece
| | - E Papachristou
- University Hospital of Patras, Transplantation Center, Patras, Greece
| | - M Papasotiriou
- University Hospital of Patras, Transplantation Center, Patras, Greece
| | - E Savvidaki
- University Hospital of Patras, Transplantation Center, Patras, Greece
| | - V Zavvos
- University Hospital of Patras, Transplantation Center, Patras, Greece
| | - D Karavias
- University Hospital of Patras, Transplantation Center, Patras, Greece
| | - D S Goumenos
- University Hospital of Patras, Transplantation Center, Patras, Greece.
| | - J G Vlachojannis
- University Hospital of Patras, Transplantation Center, Patras, Greece
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Anemia control in kidney transplant recipients using once-monthly continuous erythropoietin receptor activator: a prospective, observational study. J Transplant 2014; 2014:179705. [PMID: 24883202 PMCID: PMC4026977 DOI: 10.1155/2014/179705] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/24/2014] [Accepted: 03/24/2014] [Indexed: 12/17/2022] Open
Abstract
In a multicenter, prospective, observational study of 279 kidney transplant recipients with anemia, the efficacy and safety of once-monthly continuous erythropoietin receptor activator (C.E.R.A.) were assessed to a maximum of 15 months. The main efficacy variable was the proportion of patients achieving a hemoglobin level of 11-12 g/dL at each of visits between months 7 and 9. At study entry, 224 patients (80.3%) were receiving erythropoiesis stimulating agent (ESA) therapy including darbepoetin alfa (98), epoetin beta (61), and C.E.R.A. (45). The mean (SD) time between C.E.R.A. applications was 34.0 (11.9) days. Among 193 patients for whom efficacy data were available, mean (SD) hemoglobin was 11.1 (0.99) g/dL at study entry, 11.5 (1.1) g/dL at month 7, 11.6 (1.3) g/dL at month 9, and 11.4 (1.1) g/dL at month 15. During months 7–9, 20.7% of patients had all hemoglobin values within the range 11-12 g/dL and 64.8% were within 10–13 g/dL. Seven patients (2.5%) discontinued C.E.R.A. due to adverse events or serious adverse events. In this observational trial under real-life conditions, once-monthly C.E.R.A. therapy achieved stable hemoglobin levels in stable kidney transplant recipients with good tolerability, and with no requirement for any dose change in 43% of patients.
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Wu Z, Guo J, Liao L, Wu W, Yang S, Tan J. Prevalence and management of post-transplant anemia in long-term follow-up of Chinese kidney transplant recipients: a single-center report. Eur J Med Res 2013; 18:45. [PMID: 24237955 PMCID: PMC3835543 DOI: 10.1186/2047-783x-18-45] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 11/06/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Post-transplant anemia (PTA) has long been a less-recognized complication in kidney transplant recipients, and its prevalence also tends to be underestimated. This study sought to evaluate the prevalence, management, and risk factors of PTA from a group of long-term follow-up Chinese kidney transplant recipients. METHODS One hundred and fifty-four adult kidney transplant recipients were followed up at Fuzhou General Hospital, China, and retrospectively studied. RESULTS PTA prevalence at transplant and at 5-yearly time points after transplantation were 45.5%, 10.7%, 9.6%, 14.8%, 13.5%, and 19.6%, respectively. Overall, 38.3% of patients had been anemic at least once during the follow-up period, and 42% of these patients had recurrent anemia. Correlation analysis indicated that hemoglobin levels were associated with graft function. No correlations between anemia and age, gender, immunosuppressive regimens, or antihypertensive agents were observed. Binary logistic regression analysis suggested that serum creatinine and blood urea nitrogen were associated with the diagnosis of anemia at 1 year post-transplant. At 5 years post-transplant, only serum creatinine concentrations correlated with anemia. Although iron drugs are frequently used, erythropoietin was rarely administered in those anemic patients suffering poor graft function that necessitated such therapies. CONCLUSIONS The prevalence of PTA is noticeably high, and impaired kidney graft function seemed to be the major risk factor for anemia. There is an urgent need to improve current PTA management and to establish modified guidelines for this common complication in kidney transplant recipients.
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Affiliation(s)
| | | | | | | | | | - Jianming Tan
- Organ Transplant Institute, Fuzhou General Hospital, Xiamen University, 156 West Er'huan Road, Fuzhou 350025, China.
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Reindl-Schwaighofer R, Oberbauer R. Blood disorders after kidney transplantation. Transplant Rev (Orlando) 2013; 28:63-75. [PMID: 24211181 DOI: 10.1016/j.trre.2013.10.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Revised: 09/21/2013] [Accepted: 10/01/2013] [Indexed: 02/07/2023]
Abstract
Post transplant anemia (PTA) is a common issue in kidney transplant recipients. Most importantly it is associated with an impaired allograft function. Other important factors associated with PTA are immunosuppressive drugs (MPA, AZA and SRL), iron deficiency, infections (Parvo B19), older donor age, rejection episodes, an increased inflammatory state, and erythropoietin hyporesponsiveness. As there are no adequately powered RCTs in the kidney transplant population on anemia treatment with ESA, we have to rely on what we know from the large RCTs in the CKD population. The recently published KDIGO guidelines do not recommend treatment with ESA if Hb is >10 g/dl. Repletion of iron stores is emphasized. Post transplant leukopenia (PTL) and thrombocytopenia (PTT) are frequent complications especially in the first six months after kidney transplantation. Myelosuppression caused by immunosuppressive agents (MPA, AZA, SRL, rATG), antimicrobial drugs (VGCV), and CMV infection is the predominant cause. There are no widely accepted guidelines on treatment strategies, but most often dose reduction or discontinuation of causative medication is done. Most clinicians tend to decrease MPA dose, but this is eventually associated with an increase in acute rejection episodes. VGCV dose reduction (preemptive treatment instead of CMV prophylaxis) may be a successful strategy. In severe cases G-CSF treatment is an important management option and seems to be safe.
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Affiliation(s)
| | - Rainer Oberbauer
- Department of Nephrology, KH Elisabethinen, Linz, Austria; Department of Nephrology, Medical University of Vienna, Vienna, Austria.
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Schjelderup P, Dahle DO, Holdaas H, Mjøen G, Nordby G, Abedini S, Jardine A, Fellström B, Svensson M. Anemia is a predictor of graft loss but not cardiovascular events and all-cause mortality in renal transplant recipients: follow-up data from the ALERT study. Clin Transplant 2013; 27:E636-43. [DOI: 10.1111/ctr.12220] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2013] [Indexed: 02/06/2023]
Affiliation(s)
| | - Dag Olav Dahle
- Medical Department; Oslo University Hospital Rikshospitalet; Oslo Norway
| | - Hallvard Holdaas
- Medical Department; Oslo University Hospital Rikshospitalet; Oslo Norway
| | - Geir Mjøen
- Medical Department; Oslo University Hospital Rikshospitalet; Oslo Norway
| | - Gudrun Nordby
- Medical Department; Oslo University Hospital Rikshospitalet; Oslo Norway
| | | | - Alan Jardine
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
| | - Bengt Fellström
- Division of Nephrology; Department of Internal Medicine; University of Uppsala; Uppsala Sweden
| | - My Svensson
- Department of Nephrology; Aarhus University Hospital; Aarhus Denmark
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Vanhove T, Kuypers D, Claes KJ, Evenepoel P, Meijers B, Naesens M, Vanrenterghem Y, Cornelis T, Bammens B. Reasons for dose reduction of mycophenolate mofetil during the first year after renal transplantation and its impact on graft outcome. Transpl Int 2013; 26:813-21. [PMID: 23746202 DOI: 10.1111/tri.12133] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 02/11/2013] [Accepted: 05/15/2013] [Indexed: 11/29/2022]
Abstract
UNLABELLED Mycophenolate mofetil (MMF) decreases the risk of acute rejection and is associated with improved graft survival in renal transplant recipients. However, MMF-related side effects often necessitate dose reduction, which may expose patients to a higher risk of acute rejection and graft loss. This study's aim was to examine the reasons for MMF dose reduction during the first post-transplant year and its impact on acute rejection, overall and death-censored graft loss. METHODS Single-center retrospective analysis of 749 renal transplant recipients treated with MMF in their initial maintenance immunosuppressive protocol. RESULTS In 365 patients (48.7%) a total of 530 MMF dose reductions were done. Reasons for reduction were hematologic toxicity (46.5%), infection (16.1%), gastrointestinal side effects (12.3%), malignancy (2.1%), study protocol (14.6%), and unknown (13.5%). MMF dose reduction as such was not an independent predictor of acute rejection or graft survival, although reductions in ≥ 50% of initial dose were significantly associated with acute rejection. CONCLUSIONS In this retrospective cohort, by far the most important reason for MMF dose reduction during the first post-transplantation year was hematologic. MMF dose reductions in ≥ 50% increased the risk of acute rejection but did not compromise graft survival.
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Affiliation(s)
- Thomas Vanhove
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospitals Leuven, Belgium
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Icardi A, Paoletti E, De Nicola L, Mazzaferro S, Russo R, Cozzolino M. Renal anaemia and EPO hyporesponsiveness associated with vitamin D deficiency: the potential role of inflammation. Nephrol Dial Transplant 2013; 28:1672-9. [PMID: 23468534 DOI: 10.1093/ndt/gft021] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Resistance to erythropoiesis-stimulating agents (ESAs) has been observed in a considerable proportion of patients with chronic kidney disease (CKD) and it is reportedly associated with adverse outcomes, such as increased cardiovascular morbidity, faster progression to end-stage renal disease (ESRD) and all-cause mortality. The major causes of ESA resistance include chronic inflammation producing suppressive cytokines of early erythroid progenitor proliferation. In addition, pro-inflammatory cytokines stimulate hepcidin synthesis thus reducing iron availability for late erythropoiesis. Recent studies showing an association in deficiencies of the vitamin D axis with low haemoglobin (Hb) levels and ESA resistance suggest a new pathophysiological co-factor of renal anaemia. The administration of either native or active vitamin D has been associated with an improvement of anaemia and reduction in ESA requirements. Notably, these effects are not related to parathyroid hormone (PTH) values and seem to be independent on PTH suppression. Another possible explanation may be that calcitriol directly stimulates erythroid progenitors; however, this proliferative effect by extra-renal activation of 1α-hydroxylase enzyme is only a hypothesis. The majority of studies concerning vitamin D deficiency or supplementation, and degree of renal anaemia, point out the prevalent role of inflammation in the mechanism underlying these associations. Immune cells express the vitamin D receptor (VDR) which in turn is involved in the modulation of innate and adaptive immunity. VDR activation inhibits the expression of inflammatory cytokines in stromal and accessory cells and up-regulates the lymphocytic release of interleukin-10 (IL-10) exerting both anti-inflammatory activity and proliferative effects on erythroid progenitors. In CKD patients, vitamin D deficiency may stimulate immune cells within the bone marrow micro-environment to produce cytokines, inducing impaired erythropoiesis. Immune activation involves the reticuloendothelial system, increasing hepcidin synthesis and functional iron deficiency. Consequences of this inflammatory cascade are erythropoietin (EPO) resistance and anaemia. Given the key role of inflammation in the response to EPO, the therapeutic use of agents with anti-cytokines properties, such as vitamin D and paricalcitol, may provide benefit in the prevention/treatment of ESA hyporesponsiveness.
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Affiliation(s)
- Andrea Icardi
- Nephrology and Dialysis Unit, La Colletta and Villa Scassi Hospitals-ASL 3, Arenzano and Genoa, Italy
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Kuypers DR. Pharmacogenetics in solid organ transplantation: a transition from kinetics to dynamics. Pharmacogenomics 2012; 13:1679-83. [PMID: 23171332 DOI: 10.2217/pgs.12.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Dirk Rj Kuypers
- Department of Nephrology & Renal Transplantation, University Hospitals Leuven, Catholic University of Leuven, Herestraat 49, B-3000 Leuven, Belgium.
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Anemia in Kidney Transplants Without Erythropoietic Agents: Levels of Erythropoietin and Iron Parameters. Transplant Proc 2012; 44:2590-2. [DOI: 10.1016/j.transproceed.2012.09.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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