Post-transplant renal anaemia: a call to action from a national study in routine clinical practice

Abstract

Background Post-transplant anaemia is a prevalent yet often overlooked condition that poses significant risks. Current guidelines consider the same treatment recommendations and goals for these patients as for chronic kidney disease patients not on dialysis (CKD-NDD). Previous old reports demonstrated lack of awareness and suboptimal management indicating a pressing need for improvement. We therefore wanted to update this information on post-transplant anemia. Aims To describe the present state of anaemia management, goals, and adherence to guidelines within a representative sample of the kidney transplant (KTx) population. Methods We designed a retrospective nationwide multicentre study including outpatients from 8 KTx hospitals. Nephrologists gathered data from electronic medical records encompassing demographics, comorbidities, KTx characteristics and immunosuppressive therapy and information pertaining to anaemia management (laboratory values, previously prescribed treatments, and subsequent adjustments). The European statement on KDIGO guidelines was the reference for definitions, drug prescriptions and targets. Anemia occurring within the initial six months post-transplantation was classified as early onset. Results We included 297 patients with post-transplant anemia aged 62.8 (SD 13.6) and 60% male. They had received a graft from cardiac-death or brain-death donors (61.6% and 31.1%, respectively) a median of 2.5 years [0.5–8.7] before. Among them 77% (n = 228) were classified as having late post-transplant anemia, characterized by a higher prevalence of microcytic and iron deficiency anemia. A total of 158 patients were on erythropoietic stimulating agents (ESAs) treatment, yet surprising 110 of them lacked iron supplementation. Notably, 44 patients had an indication for iron supplementation and among them, 30 exhibited absolute iron deficiency. Out of the 158 patients receiving ESAs, only 39 surpassed the limit for the ESA resistance index indicating poor response. This resistance was more frequent among patients with early post-transplant anemia (26.1 vs 9.2%). We have identified iron profile, early post-transplant anemia and eGFR as factors associated with the highest risk of resistance Conclusion We found that Hb targets are individualized upwards in post-transplant anemia. In this setting, iron therapy continues to be underutilized, especially intravenous, and iron deficiency and prior events (blood transfusion or hospital admission) explain most of the hyporesponsiveness to ESA. This highlights missed opportunities for precise prescription targeting and adherence to established guidelines, suggesting a need for improved management strategies in post-transplant anemia patients.