Post-transplant anemia (PTA) likely influences the risk of graft failure, according to investigators presenting at the American Transplant Congress.

In an analysis of data from 1307 adult kidney transplant recipients, 43.6% had PTA at 7 years after transplantation, Yoichi Kakuta, MD, of Tokyo Women’s Medical University, and collaborators reported. Of the 96 graft failures, 88 occurred in the PTA group and 8 in the no PTA group. A 1 g/dL reduction in hemoglobin was associated with a significant 1.8-fold increase in graft failure.

PTA showed an interaction with time-averaged estimated glomerular filtration rate (eGFR). For recipients with a high eGFR, the 7-year cumulative graft failure rate was 7.7% in the PTA group vs 1.8% in the no PTA group. For those with low eGFR, the rates were 19.9% vs 2.1%, respectively.

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The investigators observed no significant differences in dose of methylprednisolone or mycophenolate mofetil or in tacrolimus trough level by patients’ anemia status. Anemic recipients were more likely to receive erythropoiesis stimulating agents (ESA) and renin-angiotensin system blockers.

“Our findings implied that we should take into account not only Hb levels but also allograft function while determining the treatment strategy for PTA,” Dr Kakuta and the team concluded in their study abstract.

“It is my personal opinion that there should be a PTA management algorithm to correct anemia and vigilance for chronic rejection surveillance to avoid early graft loss,” said Edgardo Laurel, MD, a transplant nephrologist at Banner–University Medicine Transplant Institute in Phoenix, Arizona, who was not involved with the study.

Clinicians should treat PTA with ESAs and intravenous iron, especially if patients’ eGFR is below 60 mL/min/1.73 m2 and iron indices are low, Dr Laurel said.

Clinicians should avoid excessive dosing with ESAs and be careful not to raise Hb levels above 12 g/dL, he said.

The new study is not the first to associate PTA with graft loss. A previous study of 1139 kidney transplant recipients, which was published in BMC Nephrology (2019;20:51), found that any PTA was associated with a significant 3-fold and 1.8-fold increased risk of death-censored graft failure 180 to 1251 days post-transplant (early period) and 1252 days post-transplant and beyond (late period), respectively. Severe PTA (Hb level below 11 g/dL) was associated with significant 7.6- and 2.6-fold increased risks, respectively, in the early and late periods.

Dr Laurel cited a study published in Transplantation Proceedings (2015; 47:1178-1181) showing that PTA contributes to cardiovascular morbidity by deteriorating left ventricular function and increasing carotid-femoral pulse wave velocity, and this contributes to worse graft function. In another study of kidney transplant recipients published in Transplantation Proceedings (2016;48:878-883), investigators demonstrated that PTA was associated with an increased risk of a 50% or greater increase in serum creatinine level, a return to chronic dialysis, or subsequent kidney transplantation.

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Kakuta Y, Okumi M, Kanzawa T, et al. The interaction between post-transplant anemia and allograft function in kidney transplantation. Presented at the 2019 American Transplant Congress in Boston. Abstract C84.