Immune thrombocytopenic purpura presenting in a patient after renal transplant for diabetic nephropathy

Abstract

BackgroundImmune thrombocytopenic purpura (ITP) is primarily characterized by immune-mediated destruction of platelets in circulation. Major treatment options range from careful observation, steroids, immunosuppressive medications, immunoglobulins to splenectomy. Interestingly and rarely, ITP has also been reported after solid organ transplantation in patients receiving immunosuppressive medications. While the incidence of new onset ITP after solid organ transplant is comparatively well documented, new onset ITP after renal transplant has only been reported in two patients. Both these patients underwent renal transplant for underlying Immunoglobulin-A (IgA) nephropathy and were treated effectively with steroids. We present successful management of the first reported case of new-onset ITP presenting after renal transplant in a patient with underlying diabetic nephropathy. The case report discusses the potential management strategies in such a novel scenario aiming simultaneously for a well-functioning renal graft, adequate hemostasis, minimum therapy- related morbidity and least cost implications for the patient.Case PresentationA 43-year-old male with hypertension and diabetes mellitus (DM), complicated by nephropathy and retinopathy, underwent pre-emptive living related renal transplant by donation from his 33-year-old wife. His immediate post-transplant period was unremarkable. Six months after the transplant, he presented with isolated thrombocytopenia. An extensive workup revealed no clinical or laboratory evidence of unusual substance intake, infection, hemolysis, microangiopathy, autoimmune disease or hematological malignancy. Eight months after the transplant, while the patient was maintained on steroids, cellcept and tacrolimus, his platelet count dipped to 13,000/microL and he had an episode of mild epistaxis. He was administered steroids in line with the adult ITP management protocol. Steroids were well tolerated, and platelet counts showed a good response to therapy. Steroids were then successfully tapered over the next ten weeks with steady and acceptable platelet counts and graft function.ConclusionsThe case report discusses the diagnostic considerations and successful management of new-onset post-renal transplant ITP. It also highlights the various therapeutic options available in the medical armamentarium including shuffling of immunosuppressive drugs, rituximab, thrombopoietin receptor agonists (TPO’s) and splenectomy for their potential use in complicated scenarios like relapsing, or steroid-refractory post renal transplant ITP.

Therapeutic effects of rituximab combined with cyclophosphamide on refractory idiopathic thrombocytopenic purpura

“…It is worth noting that cyclophosphamide interferes with the production of DNA and RNA and even cross-links with DNA, which in turn inhibits the immune response and proliferation and division of immune lymphocytes and impedes the deposition of immune complexes. Cyclophosphamide has been widely used in the treatment of lymphatic systemic and autoimmune diseases (20).…”

Immune thrombocytopenia secondary to primary cytomegalovirus infection after renal transplantation treated with a thrombopoietin receptor agonist: a case report

“…In addition, cases of cytomegalovirus (CMV)-associated thrombocytopenia have also been reported [3][4][5][6][7][8]. There have been several reports of ITP after renal transplantation (RT) [4][9] [10]. However, to our best knowledge, only one of them was a case of CMV-associated thrombocytopenia [4].…”

Case Report of Thrombotic Thrombocytopenic Purpura in a Previously Healthy Adult

“…Associations have been made between iTTP and connective tissue disorders, pregnancy, certain forms of cancer, and surgeries. [3][4][5][6][7] There have also been a few reported cases of iTTP secondary to severe trauma. 8 Here, we describe a case of spontaneous iTTP in a previously healthy 24-year-old male that highlights the variability in clinical presentation of iTTP and its unique management, focusing on emergency care.…”