Anemia In Kidney Transplant Recipients Research Articles

#3090 Parvovirus infection in renal transplant recipients: a systematic review of clinical profile and treatment strategies

Abstract Background and Aims Parvovirus B 19 (PVB-19) virus infection can cause severe, persistent and/or refractory anaemia in kidney transplant recipients (KTR). There is paucity of data on the clinical manifestations, diagnosis and management of this infection and limited to case reports and case series. Method We performed a literature search of kidney transplant recipients infected with PVB-19 in MEDLINE, EMBASE and Cochrane databases and 93 articles were identified as suitable for assessment. The review was conducted in accordance with PRISMA statement. Results A total of two hundred and eighty-two patients were included from the studies assessed in the review. The mean age of the cohort was 37.05 years. The infection was more common in males when compared to females. The median onset of PVB-19 infection post transplantation was at 5 weeks (2, 15 weeks). One fourth of the recipients had at least one episode of rejection prior to PVB-19 infection. Majority of the patients were on Tacrolimus, MMF and corticosteroids maintenance. One third of the patients had co-infections with other organisms (EBV, CMV, etc.). Anemia and fever were the most common manifestations among all the kidney transplant patients infected with PVB-19 while CNS manifestations and rash were least reported. Hemoglobin was low (<10 mg/dl) in ninety eight percent of the patients (n=151). The lowest hemoglobin reported in the due course of illness was 6 mg/dl (5, 7.2 mg/dl) and with corrected reticulocyte count being only 0.2% (0.1%, 0.6%). The most consistent finding on peripheral smear was normocytic, normochromic anemia while a few reported helmet cells too. Pure Erythroid hypoplasia alone (45.3%) combined with giant pronormoblasts and inclusion bodies (49%) were the most common findings on bone marrow aspirate. Majority of PVB-19 diagnosis was made with the help of multiple methods of detection like IgM assay, PCR—qualitative and quantitative (42.2%). The average PCR copies detected were 1.3*107 (4.28*105, 2.53*109). IVIG only (47.2%) and combined IVIG + immunosuppression reduction (41.2%) was the mainstay of the treatment in majority. The median time to recover was 8 weeks (3, 16 weeks). One fourth of the patients had recurrence after recovery. A majority of the patients (96.7%) recovered from reactivation of PVB-19. Conclusion Parvovirus infection is not uncommon in the early post-transplant period. Though data is insufficient, immunosuppression reduction with IVIG remains the treatment of choice for affected patients. Prospective studies to assess the hemoglobin cutoffs and dose of IVIG are needed to frame screening and treatment protocols.

Parvovirus B19 infection after kidney transplantation: A single centre experience

BackgroundParvovirus B19 is an uncommon cause of anaemia in kidney transplant recipients (KTRs). The study aims to determine the incidence, clinical presentation, laboratory findings and outcome of parvovirus B19-related anaemia in KTR. MethodWe conducted a 12-year retrospective, single-centre study describing the clinical profile of KTRs with parvovirus B19-related anaemia. ResultAmongst the 714 patients who underwent kidney transplantation between January 2011 and January 2023, (cumulative follow-up: 1287 patient-years), six females and one male, developed parvovirus B19-related anaemia. The incidence proportion (risk) is 0.98% with an incidence rate of 5.43 cases per 1000 patient-year. The median duration from transplant to development of anaemia was 6 weeks (range: 4–40 weeks). The mean fall in haemoglobin was 2.88 ± 1.55 gm/dl; concomitant leukopenia and thrombocytopenia were observed in 57.1 and 28.6% of patients. Three patients responded to a reduction in immunosuppression, the four non-responders required the administration of low-dose intravenous immunoglobulin. The mean duration from initiation of therapy to a sustained rise in haemoglobin was 7.71 ± 2.62 weeks. None of the patients had a relapse of the infection. ConclusionsParvovirus B19 infection is an uncommon cause of post-transplant refractory anaemia. The key to successfully managing such patients includes a high index of suspicion, early diagnosis and reduction of immunosuppression with or without administration of intravenous immunoglobulin.

Efficacy and safety of HIF-PHI for posttransplant anemia in kidney transplant recipients

Efficacy and safety of HIF-PHI for posttransplant anemia in kidney transplant recipients

P8.155: Current Trends in Anemia Treatment in Kidney Transplant Recipients

Background and Aims: The topic of management of chronic kidney disease (CKD) anemia has constantly been improving. This study aimed to assess the prevalence and current trends in anemia treatment in real-world kidney transplant recipients (KTR). Methods: This cross-section study included 509 KTR patients, mean age – of 53 years, 51.5% male, with functioning grafts in the late post-transplant period in the last quarter of 2021, in an average of 9,4 years post-transplantation. Data were analyzed using SPSS Statistics 27.0. Student’s t-test, Chi-squared test, Pearson correlation tests were used. According to the Kidney Disease: Improving Global Outcomes (KDIGO) definition, anemia was determined as a hemoglobin (Hb) level of <120 g/L for women and <130 g/L for men. CKD stage was determined by the estimated glomerular filtration rate (eGFR) calculated using creatinine in the CKD-EPI equation. Results: The prevalence of anemia in the KTR population was 35% (n=178), increasing from 13% to 96% by progressing CKD from stage 1 to 5 in a transplant (Table 1: The prevalence of anemia depends on the stage of CKD in a transplant.).A moderately strong Pearson correlation was recognized between the stage of CKD and anemia (r=0.441; p<0.001). A statistically significant association (p<0.001) was detected between anemia and the female gender (n=107; 60% of all anemic patients). We found no significant association between anemia and the use of mycophenolate or calcineurin inhibitors. Still, there was a statistically significant association between steroid use and anemia (p=0.041), with a 31% (Odds Ratio = 0.69) less chance of anemia in a group that received steroid therapy. 90% of anemic patients had normochromic, normocytic anemia, 7,8% hypochromic, microcytic, and 2,2% hyperchromic, macrocytic anemia. The treatment involved iron replacement in 29% (n=51) of patients, of whom 92.2% had oral medication and 7.8% intravenous. 54% (n=96) of anemic KTR received treatment with erythropoiesis-stimulating agents (ESAs): 27,1% with darbepoetin alfa and 72,9% with methoxy polyethylene glycol-epoetin beta. Anemia was corrected up to Hb level >110 g/L in 69.7% (n=67) of ESAs receiving KTR. A statistically significant correlation was not detected between the ESAs dosage (µg/kg) and the correction of the anemia (p=0.217). Conclusion: Like in the general CKD population, the prevalence of anemia in KTR increases as CKD progress in a transplant. The extent of anemia correction seems insufficient, although it includes both major components: iron replacement and ESAs. We found anemia more prevalent in female patients and those not receiving steroids in the immunosuppressive regimen. This last unexpected finding needs further exploration. Darja Golubeva for data collection. Ieva Evelina Stolcere for data collection. Liana Linda Lice for data collection.

Assessment risk factors and different lines of treatment of anemia in kidney transplant recipients

Assessment risk factors and different lines of treatment of anemia in kidney transplant recipients

Interventions for post-transplant anaemia in kidney transplant recipients

Interventions for post-transplant anaemia in kidney transplant recipients

Parvovirus B19-Associated Anemia in Kidney Transplant Recipients: A Single-Center Experience

Parvovirus B19 (PVB19) has tropism to red blood cell progenitors and can be reactivated after organ transplantation. The aim of study was to describe clinical manifestations, laboratory findings, treatments used, and effectiveness in kidney recipients at Viet Duc hospital. A retrospective descriptive study was performed on 663 kidney recipients who were on regular follow-up from 2000 to 2018. PVB19 was detected by polymerase chain reaction PVB19-DNA.Effectiveness of therapy was assessed by Hemoglobin level. Nine out of 663 kidney recipients (1.4%) were diagnosed with PVB19-associated anemia. Eight of these 9 (89%) were diagnosed within the first 3 months following transplantation. All patients had normoscopic anemia; the average reticulocyte proportion and count were 0.15 ± 0.04% and 0.0039 ± 0.0011T/L, respectively. Graft dysfunction was observed in 4/9 (45%) patients. Treatment included reduction of immunosuppression, intravenous immunoglobulin (IVIG), and blood transfusion. All patients responded well to treatment except 1 (11%), who experienced relapse after using low dose of IVIG.PVB19-associated anemia usually occurred early after transplantation and was associated with very low reticulocyte proportion and count. Actual treatment was effective, but the risk of relapse was present.

Treating Posttransplant Anemia With Erythropoietin Improves Quality of Life but Does Not Affect Progression of Chronic Kidney Disease.

Posttransplant anemia affects 30% to 45% of kidney transplant recipients and is associated with increased morbidity. However, there is lack of evidence about safe hemoglobin levels after erythropoietin treatment. Studies are needed to better understand the potential benefits and risks, as well as to define safe target hemoglobin ranges in these patients. In this single-center exploratory, open-label randomized controlled trial, kidney trans-plant recipients with anemia 3 months posttransplant were either treated with epoetin beta to a hemoglobin target level of 11.5 to 13.5 g/dL (n = 28) or given no treatment (n = 27). Treatment effects on graft function and health quality of life were assessed. After 2 years, hemoglobin concentrations were significantly higher in the epoetin beta treatment group than in the no treatment group (12.3 ± 0.18 vs 9.99 ± 0.22 g/dL; P < .0001). Estimated glomerular filtration rate, calculated by Modified Diet in Renal Disease 7, declined by 1.7 mL/min (interquartile range, -6 to 4.24) in the epoetin treatment group and by 4.16 mL/min (interquartile range, -12.42 to 2.78) in the no treatment group (P = .32). Rate of progression, determined by estimated glomerular filtration rate slope, was not significantly different between groups (-0.09 ± 0.1 vs -0.12 ± 0.15 mL/min for treated vs not treated; P = .78). Moreover, we observed no significant differences in proteinuria and blood pressure. Treated patients had greater improvements in the vitality and mental health domains of the Medical Outcomes Short Form Health Survey quality of life scores. Treatment of anemia in kidney transplant recipients to a hemoglobin level of 11.5 to 13.5 g/dL with erythropoietin improves some quality of life scores. The treatment was safe and not associated with adverse outcomes. There were no changes in rate of decline of graft function.

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

BackgroundAnaemia 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.MethodsWe 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.ResultsA 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.ConclusionsAnaemia 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.

Management of chronic parvovirus infection in postkidney transplant with prophylactic intravenous immunoglobulin therapy

Parvovirus (PV) infection is a rare cause of persistent anemia in kidney transplant recipients. The diagnosis of PV infection depends on a high index of suspicion, persistent anemia, red cell aplasia in the bone marrow, and positive polymerase chain reaction for PV B19. Treatment with intravenous immunoglobulin (IVIg) has shown to improve anemia but persistence of PV is common after treatment. This case report highlights a postkidney transplant recipient who had PV infection, treated with IVIg but had multiple relapses. He was managed with monthly IVIg prophylactic therapy for 6 months following which he had complete clearance of PV. PV B19 results in multiple relapses in postkidney transplant patients. Monthly prophylaxis therapy with higher dose delivery of IVIg can result in the clearance of PV and relapse-free response. Further studies may be required to determine the duration of prophylaxis therapy.

Posttransplantation anemia in kidney transplant recipients: A retrospective cohort study.

We sought to assess the frequency and predictors of early and late posttransplantation anemia (PTA). In addition, we aimed to assess the outcomes of patients with anemia and to assess the impact of anemia on mortality, graft function, and graft failure.Patients who underwent kidney transplantation in a single center during a 4-year period were included. Predictors associated with the development of anemia at 6 months (early PTA) or 2 years (late PTA) were evaluated in a univariate and multivariate analyses. The effects of anemia and other variables on mortality and graft function were assessed.A total of 266 kidney transplant recipients were included. The prevalence of PTA at 6 months (early PTA) was 51.3% and at 2 years (late PTA) was 36.6%. Female sex was significantly associated with early PTA. Patients with early PTA proceeded to late PTA. Patients with both early and late PTA had a higher mortality rate at 4 years compared to patients without anemia. On multivariable analysis, lower Hb at 2 years posttransplantation (hazard ratio [HR] 0.716, 95% confidence intervals [CI] 0.541–0.948, for every increment of 1 g/dL) was significantly associated with mortality. Patients with late PTA suffered a decline in eGFR compared to patients without anemia (P = .026). Furthermore, a lower Hb at 2 years posttransplantation was also associated with graft failure (HR 0.775, 95% CI 0.619–0.969, for every increment of 1 g/dL).Post-transplantation anemia is significantly associated with late mortality, with a decline in graft function and with an increased incidence of graft failure.

Zonulin, Iron Status, and Anemia in Kidney Transplant Recipients: Are They Related?

BackgroundIn patients after kidney transplantation, anemia is relatively common and is associated with impaired kidney function, subclinical inflammatory state, and immunosuppressive treatment. Zonulin-prehaptoglobin-2, a newly discovered protein, is necessary for integrity of intracellular tight junctions in the gut. Taking into consideration iron metabolism, including its absorption in the gut, we designed a cross-sectional study to look for the possible interactions among zonulin, iron status, and anemia in kidney transplant recipients. MethodsThe study was performed on 72 stable kidney transplant recipients and 22 healthy volunteers. Zonulin, iron status, and inflammatory markers were assessed with the use of commercially available kits. ResultsZonulin was significantly lower in kidney allograft recipients than in healthy volunteers (P < .001). Zonulin correlated with systolic blood pressure (r = −0.33; P < .05), thyroid-binding globulin (r = 0.24; P < .05), hematocrit (r = 0.28; P < .005), hemoglobin (r = 0.32; P < .01), total protein (r = −0.33; P < .01), erythrocyte count (r = 0.26; P < .05), and fasting glucose (r = −0.25; P < .05). Zonulin was not affected by sex, type of immunosuppressive therapy, presence of diabetes, coronary artery disease, heart failure, hypertension, or cause of end-stage renal disease. Zonulin was not related to any of the iron parameters studied. In multiple regression analysis, predictors of zonulin were total protein and thyroglobulin-binding protein, explaining 46% of variation. ConclusionsZonulin, with its poorly defined function, does not seem to play a role in the anemia in kidney allograft recipients; however, it seems to be related to the absorption process in the gut.

Treatment of Anemia With Erythropoietin-Stimulating Agents in Kidney Transplant Recipients and Chronic Kidney Disease—Another Drawback of Immunosuppression?

Anemia is more prevalent in allograft recipients compared with glomerular filtration rate (GFR) matched patients with chronic kidney diseases. There is a paucity of data concerning the correction of anemia in the posttransplant period with erythropoietin-stimulating agents (ESA). The aim of this study was to compare the iron status, kidney function, inflammatory state, use of drugs affecting erythropoiesis (immunosuppressants ACEi/ARB) and correction of anemia using ESA in a chronic kidney disease (CKD) population versus kidney transplant recipients. We included 67 patients treated with ESA including 17 after kidney transplantation. CKD Patients with native kidneys were significantly older than allograft recipients (mean age 69 versus 51 years; P < .001, and despite similar serum creatinine and iron parameters showed an estimated lower GFR (19 mL/min versus 23 mL/min; P < .05). Median time of ESA therapy was similar among patients with native kidney CKD versus kidney recipients, but they achieved a significantly higher hemoglobin (11.04 versus 10.36 g/dL; P < .05). There was no difference between patients administered or not a mammalian target of rapamycin antagonist. None of the patients with native kidney CKD received immunosuppressive therapy, but they were prescribed ACEi more often than kidney recipients. The higher degree of anemia in kidney allograft recipient is the most probably attributed to the use of immunosuppressive drugs, despite their better kidney function and comparable iron status. This study suggested that higher doses of ESA should be employed to anemia in kidney transplant recipients.

Interventions for post-transplant anaemia in kidney transplant recipients

This protocol has been withdrawn after consultation with the authors. They are no longer able to complete this review.

Effects of Continuous Erythropoietin Receptor Activator (CERA) in Kidney Transplant Recipients

Erythropoietin-stimulating agents (ESAs) are commonly used to treat anemia in kidney transplant recipients (KTRs). Since 2007, continuous erythropoietin receptor activator (CERA) has been one of the newest recombinant ESAs to treat anemia in dialysis and nondialysis patients with chronic kidney disease. The efficacy of CERA to manage anemia has not been extensively evaluated in KTRs. We evaluated safety, efficacy, and satisfaction among KTRs treated with CERA. We enrolled 19 anemic KTRs (60 ± 9.3 y) who were treated with short-acting ESA for ≥24 weeks. They were shifted to the equivalent dose of CERA and followed for 24 weeks. We measured serum hemoglobin, hematocrit, creatinine, iron, ferritin, and transferrin. To investigate tolerance to and satisfaction with short-acting ESA and CERA, questionnaires were administered to the patients before shifting to CERA and at the end of the follow-up. After 6 months, CERA induced an increase in hemoglobin levels (12.3 ± 0.8 vs 11.2 ± 1.1 g/dL; P = .002, CERA vs short-acting ESA, respectively). In 2 patients treatment was discontinued because the hemoglobin increased to >13 g/dL. No significant differences were observed in serum iron and creatinine between short-acting ESA and CERA throughout the study. The questionnaires showed better compliance to CERA treatment with reduced pain at the injection site, which led subjects to prefer CERA to short-acting ESA. In summary, CERA showed better control of anemia compared with short-acting ESA. It was preferred by the majority of patients, mainly because of the reduced number of monthly injections. Our results demonstrated CERA to be effective, safe, and well tolerated in the management of anemia in KTRs.

Posttransplantation Anemia

Treatment of anemia in patients with chronic kidney disease is a topic of increasing interest and controversy. However, anemia in the kidney transplant recipient has received relatively little attention in the literature despite the reported high prevalence of 30% to 40%. The pathogenesis of anemia among kidney transplant recipients is usually multifactorial, including compromised graft function, iron deficiency, immunosuppressive and other medications, and an inflammatory state causing erythropoietin resistance. It is unclear whether posttransplantation anemia is causally linked to cardiovascular events and mortality. Clinicians should screen kidney transplant recipients for posttransplantation anemia and carefully weigh the potential risks and benefits of treatment on an individual basis until well-designed, prospective studies provide further insight. This article reviews the prevalence, pathogenesis, and management of anemia in kidney transplant recipients.

Treatment of Anemia With Epoetin in Kidney Transplant Recipients

The aim of this study was to analyze the prevalence and efficacy of renal anemia treated with epoetin in maintenance kidney transplant recipients in Slovenia. By the end of 2009, 107 out of 537 patients (19.9%) had been treated with epoetin. A cohort of 49 patients (45.8%) were analyzed in detail: 11 patients received epoetin alpha, 18 epoetin beta, 10 darbepoetin alpha, and 10 patients received methoxy polyethylene glycol-epoetin beta. The median epoetin dose was 0.36 µg/kg body weight per week. The median serum laboratory parameters were as follows: hemoglobin 120 g/L, hematocrit 0.36, ferritin 332 ng/mL, transferrin saturation 34%, serum creatinine 145 µmol/L, serum albumin 41 g/L, intact parathyroid hormone 79 ng/L, and C-reactive protein 3 mg/L. We concluded that the prevalence of renal anemia in kidney transplant recipients treated with epoetin was approximately 20%, and laboratory parameters suggested that the treatment of renal anemia in this study cohort was optimal.

Association of Serum Phosphorus Level With Anemia in Kidney Transplant Recipients

Anemia and mineral and bone disorders (MBD) are both important and common complications in kidney transplant recipients. Studies in patients with chronic kidney disease indicated a possible independent association of higher serum phosphorus with anemia, but similar associations have not been examined in kidney transplant recipients. We hypothesized that higher serum phosphorus is associated with anemia independent of other components of MBD. We examined the association of serum phosphorus with hemoglobin level and the prevalence of anemia in a prevalent cohort of 992 kidney transplant recipients in a single outpatient transplant center. Associations were examined in linear and logistic regression models with adjustment for demographic and comorbid conditions for various known risk factors of anemia, including measures of iron deficiency, inflammation, and components of MBD including serum levels of 25(OH) vitamin D, parathyroid hormone, and fibroblast growth factor 23. In multivariable adjusted regression models, a 1 standard deviation (0.8 mg/dL) higher serum phosphorus level was associated with 0.26 g/dL lower blood hemoglobin concentration (95% confidence intervals -0.36 to -0.15, P<0.001) and with an odds ratio for anemia of 1.77 (95% confidence intervals 1.33-2.37, P<0.001). These associations were consistent across the entire spectrum of the physiologic serum phosphorus concentration and were more accentuated in patients with lower estimated glomerular filtration rate. Higher serum phosphorus is independently associated with anemia in kidney transplant recipients.

Prevalence and Management of Anaemia in Renal Transplant Recipients: Data from Ten European Centres

Background: Although it is a known predictor of mortality, there is a relative lack of recent information about anaemia in kidney transplant recipients. Thus, we now report data about the prevalence and management of post-transplant anaemia (PTA) in Europe 5 years after the TRansplant European Survey on Anemia Management (TRESAM) study. Methods: In a cross-sectional study enrolling the largest number of patients to date, data were obtained from 5,834 patients followed at 10 outpatient transplant clinics in four European countries using the American Society of Transplantation anaemia guideline. Results: More than one third (42%) of the patients were anaemic. The haemoglobin (Hb) concentration was significantly correlated with the estimated glomerular filtration rate (eGFR) (r = 0.4, p < 0.001). In multivariate analysis, eGFR, serum ferritin, age, gender, time since transplantation and centres were independently and significantly associated with Hb. Only 24% of the patients who had a Hb concentration <110 g/l were treated with an erythropoiesis-stimulating agent. The prevalence of anaemia and also the use of erythropoiesis-stimulating agents were significantly different across the different centres, suggesting substantial practice variations. Conclusions: PTA is still common and under-treated. The prevalence and management of PTA have not changed substantially since the TRESAM survey.

The Possible Role of Early Post-Transplant Inflammation in Later Anemia in Kidney Transplant Recipients

Delayed kidney graft function and acute rejection in the early post-transplant period affect both short and long-term allograft survival. Allograft rejection, as an inflammatory state, results in increased erythropoietin resistance, which leads to decreased haemoglobin (Hb) level. We conducted this study to evaluate whether inflammation in the early post-transplant period could predict later anemia.This is a retrospective cohort study based on the analysis of 64 existing clinical records. White blood cells (WBC) count obtained by the end of the first week post-transplant (W1). Covariates: Donor's age, recipient's age and sex. Anemia identified at 12 months (M12) post engraftment. Median WBC count at W1 was 9,5 x103/microL (5th - 95th percentile 5,2 x103/microL -17,8 x103/microL). Mean Hb values at M12 were 129,9 +/- 20,3 g/L, in males 136,2 +/- 20,1 g/L and in females 119,4 +/- 16,2 g/L. The significant correlation was found between WBC at W1 and Hb at M12. Pearson coefficient of correlation r was -0,26, and 95% confidence interval (CI) for r was -0,47 to -0,015 (p=0,03). Univariate logistic regression showed significant association between WBC at W1 and Hb at M12 (OR 1,20; 95% CI 1,04 to 1,39, p=0,01). After the adjustment for donor's and recipient's age by transplantation and recipient's sex, multiple regression showed that WBC count remained predictive of anemia at M12 (OR 1,17; 95% CI 1,01 to 1,36, p=0,03). Early post-transplant inflammatory response predicts later anemia in kidney transplant recipients. An increase in WBC count in the first week post-transplant by 109/L increases the risk for anemia after twelve months by 17%.