Guideline 6.3 – Post-Transplant Anaemia

We suggest that consideration is given to identifying (and correcting) reversible transplant specific causes of anaemia. (2B)

Guideline 6.3.1

We recommend that the treatment guidelines for anaemia in kidney transplant recipients should be similar to those for people with CKD not receiving dialysis (NDD-CKD). (1B)

Guideline 6.3.2

We suggest for stable non-bleeding individuals who clinically require a red cell transfusion, using single unit transfusion, where possible. (2B)

Guideline 6.3.3

We suggest the use of HIF-PHI therapy in transplant recipients should be as in people with NDD-CKD. (2B)

Rationale

Data on the use of HIF-PHI therapy in kidney transplant recipients are limited to small case series and non-randomised real-world evidence. In the randomised controlled trials transplant patients were excluded in the majority and hence data is limited to draw any conclusions. However, in resports thus far, the use of HIF-PHI therapy appears to be effective in raising Hb levels to the current recommended target range in the short term with limited documented adverse effects (1-2). The numbers of people treated are too small to currently make any specific recommendations of use of HIF-PHI in people with a kidney transaplant (1-2). In the recent published studies from Asia, there were approximately 73 patients in the 4 studies from Asia (3-6). A growing experience exists in Europe and the UK (personal communication). A specific consideration in the transplant population, would be the additive theoretical risk of malignancy in the long term.

References

1. Nakamura N, Aso S, Nakagawa C, Tachibana M, Fujikawa A, Tsubouchi K, et al. Efficacy and Safety of Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitor Therapy for Anemia in Renal Transplantation Patients by Prior Erythropoiesis Stimulating Agent Use. Transplantation Proceedings. 2023;55(4):829-31.

2. Bonomini M, Di Liberato L, Sirolli V. Treatment Options for Anemia in Kidney Transplant Patients: A Review. Kidney Med. 2023;5(8):100681.

3. Miki K, Nakamura Y, Yokoyama T, Kamiyama M, Ishii Y. Therapeutic Effect of Roxadustat on Patients with Posttransplant Anemia. Transplant Proc. 2022;54(3):671-7.

4. Li J, Ma K, Wang L, Qi H, Lv J, Rao Y, et al. Efficacy and safety of roxadustat in the treatment of renal allograft anemia patients: a case series. Annals of palliative medicine. 2021;10(11):11859- 67. DOI; 10.21037/apm-21-2916

5. Naganuma Toshihide Experience with the Use of a Novel Agent, Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitor, for Posttransplant Anemia in Renal Transplant Recipients: A Case Report Transplantation Proceedings 2022 54(2):544-548. DOI: 10.1016/j.transproceed.2021.10.022

6. Li Hui Beneficial effect of roxadustat on early posttransplant anemia and iron utilization in kidney transplant recipients: a retrospective comparative cohort study. Annals of Translational Medicine 2022 10(24):1360-1360, DOI: 10.21037/atm-22-5897