A 57-year-old man with end-stage renal disease secondary to chronic interstitial nephritis was initiated on hemodialysis in February 2006 for uremic symptoms. In April 2006, his hemoglobin (Hgb) was 10.7 g/dl and transferrin saturation was 12.7%. He was started on subcutaneous follow-on epoetin-alfa, Wepox (Wockhardt Limited India, Mumbai, India) and 10 weekly doses of 100 mg each of iron sucrose administered intravenously. His Hgb increased to 12.3 g/dl within 2 months after the initiation of epoetin. He then underwent coronary artery bypass graft surgery for triple vessel coronary artery disease. He received two units of packed cells during the post-operative period because of a decrease in the Hgb level to 8.2 g/dl. He was continued on epoetin at the same dose. Three months later the Hgb level later was 6.6 g/dl (Figure 1). Two units of red blood cell transfusion and intravenous iron were administered, and Wepox was continued. In December 2006, his Hgb decreased further to 4.9 g/dl. Further work up of his anemia revealed that a stool sample for occult blood was negative, an upper gastrointestinal endoscopy showed an antral ulcer, and gastric biopsy for Helicobacter pylori was positive. He was treated with ampicillin, tinidazole, and omeprazole for 10 days. A repeat endoscopy, 1 month later, revealed a healed duodenal ulcer. A peripheral smear showed reduced reticulocytes (0.8%) with normal platelet and myelocyte series. His serum transferrin saturation was 97.8%. lactate dehydrogenase was 385 U/l. Parvovirus B19 serology was negative (IgM level was 9.3 U/ml (negative if less than 17 U/ml)).He received, on an average, 4 units of packed red cells per month. A bone marrow trephine (Figure 2a) and aspirate (Figure 2b) showed a selective depletion of erythroblast precursors with normal granulopoiesis and megakaryopoiesis suggestive of pure red cell aplasia (PRCA). Wepox was withheld. His serum erythropoietin level was 558 mU/ml (normal range 10-30 mU/ml). The serum anti-erythropoietin antibody assay was positive (0.9% c.p.m. at 1:100 dilution and 4.3% c.p.m. at 1:20 dilution by radioimmunoprecipitation assay (RIPA)).

Background: With the rising incidence of diabetes and hypertension, the prevalence of end-stage renal disease has increased greatly so as the need for renal replacement therapy. Availability of suitable living-related donors is a major problem which increases the demand for deceased donor renal transplantation (DDRT), making it a lifeline for the patients on dialysis without any living donors. Methodology: This is a retrospective analysis of 118 DDRT done between 2012 and 2020, in a private quaternary care hospital in a south Indian state. All patients received basiliximab induction, with maintenance immunosuppression using steroids, mycophenolate mofetil (MMF) or mycophenolate sodium, and tacrolimus. Results: In our study, we report unadjusted graft survival of 93.2% and 81.3%, patient survival of 94.9% and 83.1% at the end of 1 and 5 years, respectively. The recipients with age < 60 years had 5 years graft survival of 87%. The study group consisted of 15.25% of the patients with panel reactive antibody (PRA) positive and 10.16% of them with donor-specific antibody (DSA) during renal transplantation, and there was only one allograft loss in this subset of the patients. Conclusion: This study confirms that human leukocyte antigen matching is not very important with the current immunosuppressive protocol using tacrolimus and MMF. Early initiations of tacrolimus do not increase the incidence of delayed graft function. We report 91.6% graft survival in the DSA-positive group, with basiliximab induction and desensitization protocol.