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Anemia and iron deficiency in post-kidney transplantation: an unsolved challenge
Jose Portolés1, Rainer Oberbauer2, Michele F Eisenga3
1Dept of Nephrology & Transplantation, University Hospital Puerta de Hierro IDIPHISA, Madrid, Spain Anaemia Working Group of the Spanish Society of Nephrology (S.E.N.), Transplant Working Group of S.E.N. (SENTRA), Madrid, Spain.
Insights
Anemia and iron deficiency are common in kidney transplant recipients, impacting quality of life and outcomes. Current guidelines overlook transplant-specific factors, necessitating tailored awareness and research for these patients.
Area of Science:
- Nephrology
- Transplantation Medicine
- Hematology
Background:
- Anemia and iron deficiency (ID) are prevalent complications in kidney transplant recipients (KTRs).
- Existing anemia guidelines inadequately address the unique pathophysiology and clinical aspects of post-transplant anemia (PTA) in KTRs compared to non-transplanted chronic kidney disease (CKD) patients.
- PTA and ID often receive less clinical attention in KTRs than in non-transplant CKD populations.
Purpose of the Study:
- To review the specific evidence regarding PTA and ID in KTRs.
- To highlight the associations of PTA and ID with patient survival, graft survival, and health-related quality of life (HRQoL).
- To discuss current management strategies and identify gaps in knowledge and treatment guidelines for PTA and ID in KTRs.
Main Methods:
- This study is a narrative review of existing literature on anemia and iron deficiency in kidney transplant recipients.
- The review synthesizes evidence on prevalence, specific pathophysiological factors, management options, and clinical outcomes.
- It critically evaluates current guidelines and therapeutic approaches relevant to KTRs.
Main Results:
- Anemia is more frequent in KTRs than in non-transplant CKD patients with similar glomerular filtration rates (GFRs) due to transplant-specific factors.
- Iron deficiency requires detection and correction with oral or IV iron, noting potential complications like hypophosphatemia with certain IV formulations.
- Current hemoglobin targets for erythropoiesis-stimulating agents may not be optimal, as higher targets have been linked to slower GFR decline in KTRs.
Conclusions:
- PTA and ID are distinct clinical issues in KTRs requiring specialized attention beyond general CKD guidelines.
- Management should focus on iron repletion and individualized hemoglobin targets, while avoiding red blood cell transfusions.
- Increased awareness and targeted clinical trials are crucial for optimizing the care of KTRs with anemia and ID.
Abstract:
Anemia and iron deficiency (ID) are common and significant complications in kidney transplant recipients (KTRs) that can affect their health-related quality of life (HRQoL) and outcomes. Current anemia guidelines equate the post-transplant situation with the anemia associated with chronic kidney disease (CKD) in non-transplanted persons, not acknowledging relevant differences ranging from pathophysiology to clinical manifestation. Nephrologists caring for these patients tend to pay less attention to post-transplant anemia (PTA) and ID than in non-transplanted persons with CKD. In this narrative review we summarize the available evidence about PTA and ID and their specifics in KTRs, including associations with patient and graft survival and poorer HRQoL. The prevalence of anemia is higher in KTRs than in non-transplanted patients with CKD for a given level of glomerular filtration rate (GFR) due to kidney transplant (KT)-specific pathophysiological factors. ID should be detected and corrected in KTRs using oral or intravenous (IV) iron. Some IV iron formulations are associated with an increased risk of hypophosphatemia a typical complication in KTRs. Current guidelines suggest the same hemoglobin targets for erythropoiesis stimulating agent therapy in transplanted and non-transplanted patients, despite the fact that a higher hemoglobin target has been associated with a slower estimated GFR decline in KT. There are insufficient data to recommend the widespread use of hypoxia-inducible factor-prolyl-hydroxylase inhibitors in PTA. Red blood cell transfusions should be avoided to minimize alosensitization. We call for increased awareness and targeted trials on anemia and ID in KTRs, accounting for the diverse and specific profiles of these patients.
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