Policy: Kidney/Pancreas Post Transplant: Leukopenia Policy
Statement: Activation Date: 05.01.2015
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 leukopenia post kidney (pancreas) transplantation.
Scope/Procedure:
Basis: Leukopenia is a common occurrence after renal transplantation and in many cases results from
immunosuppressive medications and/or viral infections. The underlying etiology of the leukopenia may
be:
1. Medications
2. Immunosuppressive agents: mycofenolate mofetil (MMF or Cellcept), mycophenolic acid
(Myfortic), azathioprine, sirolimus, Thymoglobulin
3. Antiinfective agents: valganciclovir, ganciclovir, trimetoprim-sulfametoxazole, penicillins.
4. Infections: CMV, or any viral infection.
5. Hypersplenism, especially in liver-kidney transplant recipients.
General Guidelines: The general approach to the management of leukopenia is as follows:
1. Evaluate concomitant medications, especially thymoglobulin, mycophenolate, sirolimus, or
azathioprine.
2. For all WBC <3,000, check differential
3. Rule out CMV viremia.
4. For ANC <1000:
a) If on valganciclovir 900mg daily (or renally adjusted equivalent) for CMV prophylaxis, reduce
dose by 50%
b) If on valganciclovir 450mg daily (or renally adjusted equivalent) for CMV prophylaxis, hold
valganciclovir and check weekly CMV PCRs for remainder of prophylaxis period or until ANC
recovery and valganciclovir restarted. Restart prophylaxis once ANC > 1,000
c) Reduce mycophenolate dose by 25%
d) Consider filgrastrim if clinically indicated
e) Repeat CBC with differential weekly until ANC >1,000
f) For ANC <750 or no response to above interventions:
g) Reduce mycophenolate by 50% (or additional 25%)
h) Repeat CBC with differential in 1-4 days
i) Discuss with provider based on clinical course/response
j) Consider filgrastrim if clinically indicated
5. For ANC <500 or no response to above interventions:
a) Hold mycophenolate (depending on clinical course)
b) Administer filgrastrim
c) Repeat CBC with differential every 1 – 4 days
d) If ANC <500 and patient febrile (>38 C): Admit to hospital and start broad spectrum
antibiotic coverage.
6. Reintroduce and/or increase mycophenolate dose when leukopenia corrected.
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
Approved by: Renal Transplant Leadership Group
Approval Date: 05/21/2008, 10/22/2008, 4/29/2015
Review Date: 12/09/2009
Regulatory References:
Related Policies/Procedures:
Approved By
Renal Transplant Leadership Group