Abstract: SA-PO1180
Tacrolimus-Related Transfusion-Dependent Anemia in a Kidney Transplant Recipient
Session Information
- Transplantation: Clinical - Complications, Pediatrics, and Multi-Organ Considerations
October 24, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 2002 Transplantation: Clinical
Authors
- Hawkins, Ryan, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Schaefer, Heidi M., Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Richardson, Trey Howard, Vanderbilt University Medical Center, Nashville, Tennessee, United States
Introduction
Anemia is a common complication of renal transplant. While tacrolimus has rarely been identified as the primary cause of post-transplant anemia, it has previously been associated with pure red cell aplasia. Identification and management of post-transplant anemia is critical in improving transplant outcomes.
Case Description
A 29-year-old woman with ESRD due to T1DM underwent simultaneous kidney pancreas transplant. Her course was complicated by acute T-cell mediated rejection 4 months post-transplant requiring treatment with IV methylprednisolone and thymoglobulin. Her blood counts remained stable until 17 months post-transplant when her hemoglobin declined from 15.1g/dL to 6.0g/dL while her leukocyte and platelet counts remained normal. She had no active bleeding and infectious work up including parvovirus PCR was negative. Hematologic evaluation revealed normal iron studies, B12 and folate. No schistocytes were noted on the peripheral smear, and SPEP/UPEP were negative for monoclonal protein. Bone marrow biopsy was performed and showed mild hypocellular marrow with trilineage hematopoiesis, relatively decreased erythropoiesis, no dysplasia, and no increased in blasts. She required red blood cell transfusions every two weeks until the decision was made to transition tacrolimus to cyclosporine. Within 6 weeks of the change, her hemoglobin normalized to 14.5g/dL.
Discussion
Post-transplant anemia is one of many hurdles renal transplant recipients must overcome. Graft dysfunction, immunosuppressive medications, and infectious complications can each lead to impaired hematopoiesis. Our patient developed anemia requiring bi-weekly red blood cell transfusions. Her hematologic evaluation was suggestive of pure red cell aplasia without reduction in leukocyte or platelet counts--a rare manifestation of anemia post-transplant.
After investigating more common causes of anemia post-transplant, it was postulated that she had drug-induced anemia with tacrolimus being the offending agent. Transitioning to cyclosporine led to rapid recovery of the patient’s hemoglobin. The underlying mechanism for tacrolimus induced anemia is unclear but may involve immune dysregulation and autoantibody formation or direct drug-induced antibody formation. Persistent anemia requiring transfusions can trigger development of anti-HLA (human leukocyte antigen) antibodies, which increases the risk of rejection and graft failure.