Policy: Kidney/Pancreas Post Transplant: Management of Anemia
Statement: Activation Date: 05/21/2008
Affected Departments: Emory University Hospital’s Kidney (Pancreas) Transplant Programs
Vision Strategy: Patient Care
Protocol Statement: These guidelines are to be used by Emory Kidney (Pancreas) Transplant team
clinicians for the management of anemia post kidney (pancreas) transplantation.
Scope/Procedure:
Basis: Anemia is a common occurrence after renal transplantation. Multiple causes account for this
problem, including:
Relative erythropoietin deficiency: associated with delayed graft function, or chronic graft dysfunction
and renal insufficiency.
Bone marrow suppression
Medications (i.e., azathioprine, sirolimus, thymoglobulin, and less
commonly, ACE inhibitors).
Infections (Parvovirus, many viral syndromes and septic episodes).
Malignancies: PTLD, leukemia, etc.
Acute or chronic blood loss (i.e., perioperative, gastrointestinal, etc.)
Hemolysis (i.e, hypersplenism, prosthetic valves, thrombotic thrombocytopenic purpura,
hemolytic uremic syndrome, DIC, G6PD deficiency, and medications like sulfonamides,
isoniazid, and dapsone)
Iron Deficiency
Vitamin B12 and Folate Deficiency (typically causing megaloblastic changes)
Chronic inflammatory conditions
Guidelines:
A comprehensive approach to the diagnosis and management of anemia is beyond the scope of these
guidelines, but an initial assessment may include:
Medication review and physical examination.
Complete blood count to assess for other cytopenias
Stool guaiacs
Serum iron, TIBC, TSAT, ferritin and reticulocyte count
LDH levels, B 12 and Folate levels.
Management of Specific Conditions:
1) Iron deficiency (see NKF K/DOQI Guidelines, 2006)
In patients with chronic kidney disease, iron deficiency exist is ferritin <100 ng/ml and serum
transferring saturation (TSAT) is <20%.
Treatment:
Oral iron is preferred to correct iron deficiency.
If patient is intolerant to oral iron, or non-responsive to oral replacement, intravenous
iron may be given:
Iron Sucrose (Venofer ®), i.e., 200-300 mg iv x 3-4 doses over 2
week period, total dose of 1,000 mg
Sodium Ferric Gluconate (Ferrlecit ®), i.e., 125-250 mg iv x 4-8
doses over 2-3 week period, total dose 1,000 mg.
2) Relative erythropoietin deficiency
a. Early post-transplant period (1-3months).
Endogenous erythropoietin production by the transplanted kidney may be deficient in
the first 1-2 months post-transplantation, and some patients may require
erythropoietin stimulating agents (ESAs).
Suggested initial doses are:
Erythropoetin (Procrit ®) 10,000-15,000 Units sq weekly, with
weekly monitoring of hemoglobin levels.
Darbopoetin (Aranesp ®) 40-60 mcg sq weekly or every two weeks
with weekly monitoring of hemoglobin levels.
b. Late post-transplant period: Chronic allograft dysfunction with renal insufficiency.
Guidelines for the management of anemia in patients with chronic kidney disease
have been published by the National Kidney Foundation (NKF K/DOQI Anemia
Guidelines, 2006, updated in 2007) which can be accessed through the NKF website.
3) Megaloblastic Anemia: (Folate Deficiency)
Treatment: Start Folic Acid 1mg p.o. QD. up to a maximum of 5mg p.o. QD. until hematologic correction.
4) Pernicious Anemia: (B12 Deficiency)
Treatment: Vitamin B12 will be repleted either via parenteral or oral supplementation.
General guidelines:
1) Consider therapy if Hgb <11 g/dL.
2) Monitor iron stores and maintain ferritin >100 and TSAT >20-25%
3) Starting ESA dose should be based on initial hemoglobin level,
targeted hemoglobin and any special patient-related circumstances.
4) Hemoglobin should be monitored initially q2 weeks, and later
monthly.
5) Iron stores should be monitored every 1-3 months.
6) Recommended target hemoglobin level is 11-12 g/dL.
7) Rate of hemoglobin increase should not be >1 g/dL per month.
8) ESA should be held temporarily if hemoglobin >13 g/dL
9) Monitor blood pressure during ESA administration.
10) Suggested starting doses are:
erythropoietin
(Procrit®) at 100150 units/kg weekly
subcutaneously, or
darbopoetin
(Aranesp®) 40-60
mcg sq weekly or q
2 weeks.
References:
Medical Care of the Kidney Transplant Recipient after the First Posttransplant Year. Djamali et al. Clin J
Am Soc Nephrol 1: 623-640, 2006
National Kidney Foundation: KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations
for Anemia in Chronic Kidney Disease. Am J Kidney Dis 47:S1-S145, 2006 (suppl 3)
Approved by: Renal Transplant Leadership Group
________________________________________
Thomas C. Pearson, M.D., D.Phil.
Director, Emory Kidney and Pancreas Transplant Programs
Chair, Renal Transplant Leadership Group
Approval Date: 05/21/2008, 10/22/2008
Revised: 12/09/2009