Spectrum of anemia after kidney transplantation: pathophysiology and therapeutic implications

Abstract

The prevalence of anemia in the first month after transplant is 70%-80%. The rate declines to 30%-40% at 3 months and 20% by 12 months. Its occurrence is influenced by the quality of the transplanted organ, bone marrow regenerative capacity, amount of surgical blood loss, and increased iron recycling. There is also a blunted response by oxidative inflammation to the effectiveness of supranormal levels of erythropoietin (EPO) release during ischemic-reperfusion allograft injury. The prevalence rate of late-onset post-transplant anemia (PTA) is 30%-50%. This category of patients falls into two ill-defined groups: (i) those with impaired renal capacity for EPO synthesis and (ii) those with bone marrow resistance. Given the difference in pathophysiology, the current KDIGO guideline that adopts uniform therapeutic approach for the two groups may be inappropriate. Comorbidity due to iron deficiency is common. Anemia is predictive of cardiovascular morbidity and shorter graft survival. Perhaps due to concern for the safe use of EPO stimulating agent (ESA) to correct anemia, there is often inadequate treatment of late-onset PTA. However, universal application of ESA may be harmful. Therefore, clinical trials are needed to define parameters for selecting patients (e.g., EPO assay) that will benefit the most from therapy for anemia.

Development and future deployment of a 5 years allograft survival model for kidney transplantation

“…Anaemia is present in as many as 72% of patients 1 month post‐transplant, decreasing to 40% of the patients by 3 months and 20% at 1 year . The early stages of anaemia have been attributed to several factors, including: a consequence of end‐stage renal disease pre‐transplant nadir, surgical blood loss, inadequate nutrition, fluid overload, ischaemic reperfusion injury, poor graft quality, delayed graft function and known adverse effects from immunosuppressive . Late (>1 year post‐transplant) anaemia is thought to be attributable to impaired graft function, iron deficiency, female gender and adverse effects of pharmaceuticals .…”

“…The early stages of anaemia have been attributed to several factors, including: a consequence of end‐stage renal disease pre‐transplant nadir, surgical blood loss, inadequate nutrition, fluid overload, ischaemic reperfusion injury, poor graft quality, delayed graft function and known adverse effects from immunosuppressive . Late (>1 year post‐transplant) anaemia is thought to be attributable to impaired graft function, iron deficiency, female gender and adverse effects of pharmaceuticals . In two retrospective studies, HGB levels at 12‐month post‐transplant were correlated with long‐term graft outcome.…”

“…In this study, use of ESA for 2 years normalized HGB levels and produced a 95% graft survival versus 80% for the partially normalized group. However, there have been inconsistencies in the utilization and reported outcomes of ESA in long‐term post‐transplant anaemia, possibly as a consequence of the concerns regarding adverse CV events associated with the chronic use of these agents . Thus, further study into this potentially modifiable risk factor is clearly warranted.…”

“…There are other reports using analytical forecasting models in conjunction with clinical outcomes to predict early allograft rejection, delayed graft function, 3 years deceased donor graft survival, CV‐related deaths post‐transplant, and health care utilization post‐transplant . As there are numerous examples of risk‐prediction models in the transplant literature, future studies are now urgently required to determine if such models can be used as clinical‐decision aids and lead to improved outcomes . Previously, we implemented such a model for 1‐ and 3 years graft survival .…”

Impact of immediate post‐transplant parenteral iron therapy on the prevalence of anemia and short‐term allograft function in a cohort of pediatric and adolescent renal transplant recipients

“…Strategy for the treatment of PTA should be determined by the underlying pathophysiology. 7 While the correction of ID will ameliorate most cases of early-onset anemia, a significant proportion of those with late-onset anemia will benefit from EPO therapy. 17 With the compelling goal of optimizing clinical benefits, we introduced a routine administration of parenteral (IV) iron after KTX surgery in our pediatric program.…”