Roxadustat for Refractory Anemia Associated to Cytomegalovirus Infection in Kidney Transplantation

Anemia is a common complication after kidney transplantation (KT), often multifactorial and worsened by cytomegalovirus (CMV) infection, which promotes inflammation and erythropoiesis resistance through hepcidin elevation and HIF-2α inhibition. Roxadustat, a hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI), has shown promise in treating ESA-resistant anemia, though evidence in transplant recipients remains limited. We report 2 cases of ESA-refractory anemia post-KT with concurrent CMV infection successfully treated with roxadustat. Case 1: A 72-year-old woman developed anemia (Hb 8 g/dL) during asymptomatic CMV viremia despite valganciclovir, everolimus switch, and escalating ESA doses (up to 18,000 IU/wk). Roxadustat was started, and Hb recovered (11 g/dL) in 1 month. After a second anemia episode, dose adjustment restored Hb to 11.3 g/dL. The patient later died of unrelated causes. Case 2: A 78-year-old woman with recurrent CMV and inflammatory anemia (Hb 8.9 g/dL; ferritin 673 ng/mL) showed no ESA response. Roxadustat was stated and Hb raised to 14.2 g/dL in 1 month, allowing dose reduction and temporary withdrawal. Anemia recurred with new CMV viremia and responded again to roxadustat (Hb 11.6 g/dL). In both patients, we did not observe any side effects related to the use of the drug, and renal function remained stable during the follow-up. These cases support roxadustat as a valuable option in managing post-KT anemia with CMV-associated ESA resistance, by stimulating endogenous EPO, reducing hepcidin, and improving iron utilization. Further prospective studies are needed to establish its safety and efficacy in this population.