Managing ESA-Resistant Anemia in a Kidney Transplant Recipient

Anemia associated with chronic  kidney disease (CKD) results from insufficient erythropoietin production, and is usually resolved following successful kidney transplantation. However, in patients with allograft failure, CKD-associated anemia can recur.

During a poster session at the NKF Spring Clinical Meetings 2023, Cydney Purificacion, MD, and colleagues presented a case study of a patient with CKD-associated anemia that was caused by a failed allograft and resolved with allograft nephrectomy. The poster was titled Allograft Nephrectomy: A Management for Erythropoiesis-Stimulating Agent-Resistant Anemia in a Patient With a Failed Kidney Transplant.

The patient was a 42-year-old women with end-stage kidney disease of unclear etiology who underwent an uneventful related-living-donor kidney transplant. Her baseline creatinine was 0.9-1.1mg/dL. At 5 years following the transplant, she was lost to follow-up for 1 year when she had not taken immunosuppressive medications.

She presented with uremic symptoms and acute kidney injury. Results of allograft biopsy indicated combined 1b acute T-cell and antibody-mediated rejections. She was treated with pulse-dose steroids, recombinant anti-thymocyte globulin, plasmapheresis, and intravenous immunoglobulin. However, she experienced allograft failure and was initiated on dialysis. Following transition to dialysis, she was diagnosed with persistent anemia.

Results of iron studies, folate, and vitamin B-12 levels were normal. She was negative for parvovirus B19. Results of bone marrow biopsy were unremarkable and showed no evidence of hemolysis. She was treated with Micera® and Epogen® but required blood transfusion every 2 weeks to treat her symptomatic anemia. Based on a concern that her persistent erythropoiesis-stimulating agent (ESA) hyporesponsiveness was caused by chronic inflammation from her failed allograft, she underwent allograft nephrectomy. The procedure resolved her anemia and her hemoglobin was stable in the 9-10 g/dL range.

In summary, the authors said, “Common causes of ESA-resistant anemia are iron and vitamin deficiency, ongoing infections or inflammation, and occult gastrointestinal bleeding. However, our case demonstrates that a failed allograft as an ongoing source of inflammation should be considered as one of the potential causes of ESA resistance which can be treated by allograft nephrectomy.”

Source: Purificacion C, Siu MKM, Tantisattamo E, Sy J. Allograft nephrectomy: a management for erythropoiesis-stimulating agent-resistant anemia in a patients with a failed kidney transplant. Poster #185. Abstract of a poster presented at the National Kidney Foundation Spring Clinical Meetings 2023; April 11-15, 2023; Austin, Texas.