Post-liver-transplant anemia: Etiology and management

Abstract

Anemia is common after liver transplantation, with the incidence ranging from 4.3% to 28.2% depending on the criteria used to define anemia. The cause of anemia is unidentified in the majority of patients, and it is likely to be multifactorial. Immunosuppressive-medication-induced bone marrow suppression is perhaps the most common cause of unexplained anemia. Chronic blood loss, iron deficiency, hemolysis, and renal insufficiency are other potential causes of chronic anemia. Rare causes, somewhat unique to transplantation, include aplastic anemia, graft-versus-host disease (GVHD), and lymphoproliferative disease. Anemia due to immunosuppressive medication is challenging, since almost all drugs currently used for this purpose cause anemia, but the renalsparing property of sirolimus may benefit the subgroup in which renal insufficiency is contributing to anemia. Aplastic anemia is seen in young patients transplanted for non-A, non-B, non-C, fulminant hepatic failure. It is thought to be immunologically mediated, secondary to an unknown viral infection, and is associated with a grave prognosis. GVHD is another infrequent (approximately 1% of transplant recipients) but serious cause of severe anemia that carries a dismal prognosis. Lymphoproliferative disorder, too may rarely rare cause anemia and it may respond to reduction of immunosuppression. Recipients of solid-organ transplants do not mount a significant increase in erythropoietin in response to anemia. In conclusion, though there are no data on the response of anemia to erythropoietin in liver transplant recipients, it appears to benefit other solid-organ-transplant recipients with anemia. (Liver Transpl 2004;10:165-173.)

Correlation of Hematocrit and Tacrolimus Level in Liver Transplant Recipients

“…Anemia is common after liver transplantation [9]. Hematocrit can affect pharmacokinetics and whole blood distribution of tacrolimus [4].…”

Sirolimus Monotherapy Versus Sirolimus in Combination with Steroids and/or MMF for Immunosuppression After Liver Transplantation

“…In renal transplantation recipients, anemia was reported in a dose-dependent fashion, but there are no similar studies in liver transplantation recipients. The multifactorial nature of anemia after liver transplantation makes it difficult to comment on the actual drug-induced anemia in our cohort (18).…”

Practical Recommendations for Long-term Management of Modifiable Risks in Kidney and Liver Transplant Recipients

“…121,122 Therefore, special attention is warranted in patients with malnourishment and iron deficiency, which are frequent conditions among the transplant population. 123 …”

“…145,146 However, the first-generation protease inhibitors, telaprevir and boceprevir, and the combination ombitasvir/paritaprevir/ritonavir+/−dasabuvir, have a major impact on tacrolimus metabolism, increasing tacrolimus trough concentrations exponentially; therefore, these drugs should be avoided whenever possible. 147,148 The Determinants of IPV of tacrolimus 103,120,121,123,124 Factors Interventions interaction with simeprevir is less strong and tacrolimus dosage modifications should be carried out according to trough concentrations. 149 Additional and updated information may be found at www.hep-druginteractions.org.…”