Abstract: FR-PO642
Hyperparathyroidism Induced Erythropoietin Resistance After Successful Renal Transplantation
Session Information
- Trainee Case Reports - IV
October 26, 2018 | Location: Exhibit Hall, San Diego Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Reports
- 1802 Transplantation: Clinical
Authors
- Arroyo, Juan Pablo, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Binari, Laura, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Langone, Anthony J., Vanderbilt University Medical Center, Nashville, Tennessee, United States
Introduction
Resistance to erythropoietin (EPO) in the CKD-ESRD population is pervasive. Common causes include iron deficiency, chronic inflammation, medications and hyperparathyroidism. Most if not all of these conditions resolve after successful renal transplant. Post-transplant anemia can occur due to multiple factors including immunosuppressant medications, dapsone, TMP-SMX, RAAS antagonists, and viral infections (CMV, Parvovirus). We report a case of hyperparathyroidism-induced EPO resistance in a patient which was successfully treated with subtotal parathyroidectomy three-years after her transplant.
Case Description
A 36-year-old woman with a history of ESRD secondary to hypertension underwent a successful deceased donor kidney transplant managed with tacrolimus, mycophenolate mofetil and prednisone complicated by refractory anemia and hyperparathyroidism. Three years post transplantation with baseline creatinine of 1 mg/dL, she continued to require 40,000 units of subcutaneous epoetin alfa twice weekly for refractory anemia. Her hemoglobin oscillated between 6 – 7 g/dL during this time. She underwent an extensive workup that included: multiple iron panels all with >20% saturation, negative parvovirus PCR, and a bone marrow biopsy that showed mild hypocellularity. Her blood pressure management did not include ACEi/ARBs. Her initial immunosuppressive regimen included sirolimus; her anemia, however, persisted after switching to tacrolimus. Her NT-PTH was noted to be consistently above 1750 pg/mL and subsequently referred for parathyroidectomy following a sestamibi scan demonstrating multigland hyperplasia. One month following her parathyroidectomy, her anemia resolved completely and was able to stop epoetin alfa injections.
Discussion
Although hyperparathyroidism is a known cause of EPO resistance in the CKD-ESRD population, it is thought to contribute minimally to the overall burden of EPO resistance. This case highlights that isolated hyperparathyroidism in the absence of other common causes for EPO resistance (iron deficiency, medications, infection/inflammation) can cause severe EPO resistance, and must be addressed when evaluating anemia in renal transplant patients despite stable creatinine.