Severe Coombs’-Negative Autoimmune Hemolytic Anemia in a Kidney Transplant Patient

Abstract

Background/Aim: Few cases are found in the literature regarding autoimmune hemolytic anemia which is Coombs’ test positive in kidney transplant patients, although hemolytic uremic syndrome due to cyclosporin and FK506 has been well described. In the following, we describe a case of severe life-threatening Coombs’ test negative autoimmune hemolytic anemia after kidney transplantation. Methods: Soon after undergoing renal transplantation, the patient presented with hemolytic anemia. Kidney biopsy, routine Coombs’ test, gel filtration and flow-cytometric assay were undertaken. Results: Kidney biopsy ruled out hemolytic uremic syndrome; although Coombs’ test and gel filtration assay were negative, flow cytometry revealed circulating antierythrocytic autoantibodies. Conclusions: Our findings indicate that flow cytometry may be an efficient method in the diagnosis of hemolysis of unknown origin in transplant patients. We further hypothesize that the underlying mechanism of autoimmune hemolytic anemia is related to the passenger B lymphocytes in the graft.

Passenger lymphocyte syndrome in ABO and Rhesus D minor mismatched liver and kidney transplantation: A prospective analysis

“…Although the early onset of hemolysis at Day +15, the ABO nonidentical nature of the donors and the weak reactivity of DAT suggestive of low antibody titers make the etiology of PLS likely, donor attributed antibodies were not demonstrated. Other than PLS, other factors may lead to hemolysis after SOT [18][19][20][21]. Immune-mediated hemolytic anemia may be alloimmune or autoimmune.…”

Clinical and reference lab characteristics of patients with suspected direct antiglobulin test (DAT)-negative immune hemolytic anemia

“…The findings from our survey are consistent with, and expand upon, the observations from other previous studies. 13 Specifically, DAT-negative WAIHA has been associated with non-Hodgkin's lymphomas, 19,20 certain chemotherapeutic drugs (such as fludarabine, cyclophosphamide, and rituximab), 21 certain hematopoietic stem cell transplants, 22 autoimmune diseases such as Sjogren syndrome, 23 kidney transplants, 24 certain solid organ malignancies, 25 and pregnancy. 26 Similarly, our 18 DAT-positive respondents reported that their hemolytic anemia was associated with acute leukemia status post-bone marrow transplant, myelodysplastic syndrome, and sickle cell disease.…”

Hemolytic anemia after kidney transplantation: a prospective analysis

“…Other than the PLS, other factors may lead to hemolysis after organ transplantation 13‐15 . In this context it is known that immunosuppressive drugs cause immune alterations and may trigger autoimmunity.…”