Anemia in Renal Transplant Recipients?
Which is the best method to correct anemia in the kidney transplant recipient: whole blood, packed red blood cells, or erythropoietin?


Safdar Hassan Sial, MS (Urology)


A nonuremic environment is probably a prerequisite for the correction of anemia posttransplantation. Such correction relies on the expansion of the erythroid marrow and may precede the correction of anemia. As iron utilization increases after transplantation, iron deficiency may occur, and this will compound the anemia. Acute rejection episodes and the therapy used to treat them may affect the bone marrow response, as may antihypertensive medications such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). Looking at this patient's serum creatinine, we see that she clearly has a lowered creatinine clearance, and this in itself can slow or prevent optimal marrow function. Posttransplant anemia is not uncommon and can be found in up to 80% of children who receive transplants.

One may presume that her kidney dysfunction is a result of chronic allograft nephropathy, although it may be prudent to confirm this on renal biopsy prior to embarking on erythropoietin alfa (EPO) therapy. There are limited data with regard to the use of EPO posttransplantation, although its use pretransplantation is well described. Ortiz and colleagues suggest that EPO is a safe and effective therapy for anemia posttransplantation. In their study of 50 renal transplant recipients, the degree of renal dysfunction determined the time necessary to reach adequate hemoglobin levels (12 g/dL). In the group with serum creatinine levels between 151 and 250 micromol/L, the mean time to achieve the target hemoglobin was 3 months. Higher doses were required in patients on ACE inhibitors and ARBs. They observed no side effects and particularly no worsening of hypertension, although this has been described in an older study, particularly when serum creatinine levels are above 220 micromol/L. Becker and associates found a benefit of EPO in slowing the rate of loss of renal function over time, although this was not the case in all patients.

In conclusion, your patient may well benefit from EPO therapy, especially if iron stores and vitamin B12 and folate levels are adequate, immunosuppression is optimized, and antihypertensive medications are judiciously used. Monitoring of blood pressure and the response to EPO therapy must be vigilant.