Rashid Raja Muhammad, Nabi Zahid, Ansari Ahmad Zaki, Qaiser Quratul-Ain
Department of Nephrology, KRL General Hospital, Islamabad, Pakistan.
Rawalpindi Medical College, Rawalpindi, Pakistan.
BMC Nephrol. 2018 Mar 20;19(1):69. doi: 10.1186/s12882-018-0868-7.
Immune thrombocytopenic purpura (ITP) is primarily characterized by immune-mediated destruction of platelets in circulation. Major treatment options range from careful observation, steroids, immunosuppressive medications, immunoglobulins to splenectomy. Interestingly and rarely, ITP has also been reported after solid organ transplantation in patients receiving immunosuppressive medications. While the incidence of new onset ITP after solid organ transplant is comparatively well documented, new onset ITP after renal transplant has only been reported in two patients. Both these patients underwent renal transplant for underlying Immunoglobulin-A (IgA) nephropathy and were treated effectively with steroids. We present successful management of the first reported case of new-onset ITP presenting after renal transplant in a patient with underlying diabetic nephropathy. The case report discusses the potential management strategies in such a novel scenario aiming simultaneously for a well-functioning renal graft, adequate hemostasis, minimum therapy- related morbidity and least cost implications for the patient.
A 43-year-old male with hypertension and diabetes mellitus (DM), complicated by nephropathy and retinopathy, underwent pre-emptive living related renal transplant by donation from his 33-year-old wife. His immediate post-transplant period was unremarkable. Six months after the transplant, he presented with isolated thrombocytopenia. An extensive workup revealed no clinical or laboratory evidence of unusual substance intake, infection, hemolysis, microangiopathy, autoimmune disease or hematological malignancy. Eight months after the transplant, while the patient was maintained on steroids, cellcept and tacrolimus, his platelet count dipped to 13,000/microL and he had an episode of mild epistaxis. He was administered steroids in line with the adult ITP management protocol. Steroids were well tolerated, and platelet counts showed a good response to therapy. Steroids were then successfully tapered over the next ten weeks with steady and acceptable platelet counts and graft function.
The case report discusses the diagnostic considerations and successful management of new-onset post-renal transplant ITP. It also highlights the various therapeutic options available in the medical armamentarium including shuffling of immunosuppressive drugs, rituximab, thrombopoietin receptor agonists (TPO's) and splenectomy for their potential use in complicated scenarios like relapsing, or steroid-refractory post renal transplant ITP.
免疫性血小板减少性紫癜（ITP）的主要特征是循环中血小板的免疫介导破坏。主要治疗选择包括密切观察、使用类固醇、免疫抑制药物、免疫球蛋白以及脾切除术。有趣的是且较为罕见的是，在接受免疫抑制药物治疗的实体器官移植患者中也有ITP的报道。虽然实体器官移植后新发ITP的发病率有相对充分的文献记载，但肾移植后新发ITP仅在两名患者中被报道。这两名患者均因潜在的免疫球蛋白A（IgA）肾病接受肾移植，并接受类固醇治疗有效。我们报告了首例在患有潜在糖尿病肾病的患者肾移植后出现新发ITP的成功治疗病例。该病例报告讨论了在这种新情况下的潜在管理策略，旨在同时实现肾移植功能良好、充分止血、最小化治疗相关发病率以及对患者最小的成本影响。
一名43岁男性，患有高血压和糖尿病（DM），并发肾病和视网膜病变，接受了来自其33岁妻子的活体亲属肾移植。移植后的初期情况正常。移植后六个月，他出现孤立性血小板减少。广泛检查未发现异常物质摄入、感染、溶血、微血管病、自身免疫性疾病或血液系统恶性肿瘤的临床或实验室证据。移植后八个月，在患者继续使用类固醇、骁悉和他克莫司治疗时，他的血小板计数降至13,000/微升，并有一次轻度鼻出血发作。根据成人ITP管理方案给予他类固醇治疗。类固醇耐受性良好，血小板计数对治疗反应良好。然后在接下来的十周内成功逐渐减少类固醇用量，血小板计数稳定且可接受，移植肾功能良好。
该病例报告讨论了肾移植后新发ITP的诊断考虑因素和成功管理。它还强调了医学武器库中可用的各种治疗选择，包括免疫抑制药物的调整、利妥昔单抗、血小板生成素受体激动剂（TPO）以及脾切除术，它们在复发性或类固醇难治性肾移植后ITP等复杂情况下可能有用。
