Microangiopathic Hemolytic Anemia in Renal Allotransplantation Report of a Successfully Treated Case and Review of the Literature
ROBERTO L. MAGALHAES,
M.D.
WILLIAM E. BRAUN, M.D. RALPH A. STRAFFON,
M.D.
GEORGE C. HOFFMAN, M.D. JOHN R. SHAINOFF, Ph.D. GARY OSBORNE SHARAD D. DEODHAR, M.D., Ph.D. Cleveland, Ohio
The development of microangiopathic hemolytlc anemia after renal transplantation in a 17 year old white boy is reported, and the literature is reviewed. In this patient microangiopathic hemolytic anemia developed 6 weeks after renal transplantation during a second episode of rejection. Light, fluorescence and electron microscopy demonstrated the renal vascular lesion associated with this syndrome. In contrast to the other four previously reported cases of microangiopathic hemolytic anemia associated with renal allotransplantation, this patient had complete resolution of the microangiopathic hemolytic anemia with heparin therapy and improved allograft function, presumably with diminution of the vascular lesion. He survived a complicated early period after renal transplantation and has shown no recurrence of microangiopathic hemolytic anemia in the 16 months since transplantation. Special red blood cell and fibrinogen studies are discussed. The term
From the Renal Transplantation Service and the Departments of Hypertension and Nephrology, Urology, and Clinical Pathology, and the Division of Research, The Cleveland Clinic Foundation, Cleveland, Ohio. This study was supported in part by Contract NO1 Al 22536, National Institutes of Health, U.S. Department of Health, Education and Welfare. Requests for reprints should be addressed to Dr. William E. Braun. Department of Hypertension and Nephrology, The Cleveland Clinic Foundation, 900 Euclid Avenue, Cleveland, Ohio 44106. Manuscript accepted May 6, 1974. Present address: Rua Fonte da Saudade 256, ap. 302, 20,000 Rio de Janeiro, Brazil. l
662
June 1975
microangiopathic hemolytic anemia was first suggested by Symmers [I] in 1952 as a more appropriate term for thrombotic thrombocytopenic purpura, and in the following year Monroe and Strauss [2] suggested that the pathologic process in the small blood vessels in thrombotic thrombocytopenic purpura might be responsible for the hemolysis of the red blood cells. These latter investigators observed fragmented red cells in the peripheral blood of two patients with intravascular hemolysis caused by thrombotic thrombocytopenic purpura. After noting the fragmented red blood cells within the blood vessels and tissues from a patient with microangiopathic hemolytic anemia who died, they further suggested that the partially occluded blood vessels might be the actual site of red cell fragmentation and destruction. This concept was further elaborated upon by Brain [3,4] in extensive reviews of microangiopathic hemolytic anemia. Since Ehrlich’s [5] description in 1891 of fragmented erythrocytes in patients with pernicious anemia, numerous conditions have been associated with microangiopathic hemolytic anemia; they include malignant hypertension [3,4,6], periarteritis nodosa [3], systemic lupus erythematosus [3], thrombotic thrombocytopenic purpura [3,4,6], ulcerative colitis [6], preeclampsia and eclampsia [4], purpura fulminans [4], cavernous hemangioma [ 41, postpartum state [ 41, metastatic malignancy [3,4,6], hemolytic-uremic syndrome [4], glomerulonephritis [ 31, renal cortical necrosis [3] and renal allotransplantation [7,8].
The American Journal of Medicine
Volume 58
MICROANGIOPATHIC HEMOLYTIC ANEMIA-MAGALHAES
We describe a renal allograft recipient in whom microangiopathic hemolytic anemia developed in the course of rejection early in the post-transplant period. Treatment of the rejection with heparin was associated with resolution of the hemolytic anemia and improvement in renal function. Despite a further complication, a lymphocele, the patient has continued to have good renal function, and the hemolytic anemia has not recurred during a follow-up period of 18 months.
CASE REPORT A 17 year old white boy had scarlet fever and occasional sore throats at age 6 for which he was treated with penicillin. Asymptomatic proteinuria developed at age 12. His sister, one of three siblings, had scarlet fever at age 9 and died at age 18 of an unknown type of nephritis. The patient underwent a percutaneous renal biopsy on March 11, 1969, which showed diffuse sclerosing glomerulonephritis. Except for hypertension he was asymptomatic until July 28, 197 1, when oliguria developed. Because of pulmonary edema, anuria, hyperkalemia and ventricular tachycardia, peritoneal dialysis was begun on July 30, 197 1; his condition improved. Hemodialysis was started on December 9, 1971, and bilateral nephrectomies were performed on March 1, 1972. Splenectomy was not performed. The patient received a renal allograft from his mother on March 28 (Figure 1). Immunosuppressive therapy consisted of 2 mg/kg of prednisone, 5 mg/kg of azathioprine for one dose and then 2 mglkg thereafter. In addition, on the day of transplantation, the patient was given 1 g of methylprednisolone intravenously. The kidney functioned well and by the 3rd postoperative day the blood urea nitrogen had decreased to 16 mgli00 ml and the serum creatinine to 1.4 mg/lOO ml. The temperature rose to 10l°F on the 2nd postoperative day. Because blood, urine and sputum cultures were sterile, and because there was no clinical or roentgenologic source of infection, the persistence of the fever, along with a decrease in urine output and the development of hypertension, suggested rejection. Treatment with intravenous methylprednisolone was started. An intravenous pyelogram on April 6 showed no abnormality. A renal angiogram on April 10 showed a normal clearance time of the dye (2 seconds) and no vascular abnormalities. A renal biopsy performed on April 11, after a total of 10 g of intravenous methylprednisolone had been given, showed interstitial edema and mononuclear cell infiltrates around the peritubular capillaries and diffusely throughout the interstitium. Although no vascular changes were seen by light microscopy, immunofluorescence showed focal deposits of immunoglobulins G (IgG) and M (IgM), and complement in the small arteries. The serum creatinine reached a peak of 4.1 mg/ 100 ml and the blood urea nitrogen 116 mg/lOO ml on April 12. After a total of 18 g of intravenous methylprednisolone had been given, the serum creatinine and blood urea nitrogen decreased to 1.4 and 47 mg/lOO ml, respectively, on April 23, and the patient was discharged
ET AL.
from the hospital. He was receiving 60 mg of prednisone and 75 mg of azathioprine at that time. Because of swelling of the allograft, temperature of 103 OF and an increase in serum creatinine to 3.2 mg/iOO ml, the patient was readmitted to the hospital on April 28. Intravenous methylprednisolone therapy was instituted and another renal biopsy was performed on May 2. Up to the time of this renal biopsy, a total of 26 g of intravenous methylprednisolone had been given. The glomeruli showed focal necrosis, fibrinous deposits and swollen endothelial cells causing occlusion of capillary lumens. The small blood vessels showed areas of fibrinoid necrosis, markedly swollen endothelial cells, intraluminal fibrinous deposits and mononuclear cells infiltrating the vessel walls. Immunofluorescence showed focal deposition of IgM and the third component of complement (PtC) in blood vessels, tu-
v#ttl(s
Clinical course after renal transplantation showing hematologic and renal function changes, and therapy. The dose of methylprednisolone is cumulative.
Flgure
June 1975
1.
The Amerlcan Journalof Medlclne Volume 55
863
MlCROANGlOfATtiC
HEMOLYTC
ANEMIA-MAGALHAES
ET AL.
Figure 2. Left, note the large electron dense deposits (0) which have narrowed the vascular lumen (L) to an irregular, eccentric channel. En = endothelial cell; SM = smooth muscle cell. Right, the capillary lumen (L) is markedly narrowed by deposition of platelets (P) and electron dense material (0) in the subendothelial regions. Also, there is marked fusion and flattening of epithelial foot processes. Note the irregular shaped erythrocyte (Er) which appears to be trapped in the lumen and impaled on an endothelial protuberance or “spike” (S). BM = basement membrane; Ep = epithelial cell. Two per cent osmium tetroxlde; original magnification X 7,153 (left) and X 4,546 (right), reduced by 25 per cent.
bular basement membrane and Bowman’s capsule. Electron microscopic findings are presented in Figure 2. Because of the generalized softness and purplish color of the allograft and difficulty in controlling bleeding from the biopsy site, anticoagulation was not instituted immediately. The serum creatinine and blood urea nitrogen levels rose to 10.5 and 175 mg/iOO ml, respectively, on May 5, when the first of two hemodialyses was performed. Since there was no bleeding from the biopsy site during heparinization for dialysis, heparin therapy, 10,000 units daily, was instituted on May 5. At that time, the platelet count was 165,000/mm3, the total bilirubin 0.7 mg/lOO ml and the lactic dehydrogenase 215 Wroblewski units (normal: 30 to 120 units). On May 10, a reticulocyte count of 19 per cent was noted in association with a fall in the hemoglobin level from 8.4 to 6.6 g/100 ml, absent serum haptoglobin, plas-
064
June 1975
The American Journal of Medicine
Volume 59
ma hemoglobin of 15.6 mg/lOO ml (normal: 1 to 5 mg/lOO ml), urine hemosidarin, deformed shapes of the red cells, and red cell fragments, indicating microangiopathic hemolytic anemia (Figure 3). Antinuclear factor, three lupus erythematosus preparations, the glucose-6-phosphate dehydrogenase screening test, and direct and indirect Coombs’ test were negative. Stools had no occult blood. On May 11, the dose of heparin was increased to 16,000 units daily and continued for a total of 36 days when Coumadine therapy was started. By May 21, the hemoglobin level had risen to 10.3 g/ 100 ml, and the reticulocyte count had decreased to 4.1 per cent on May 28. No transfusions were given. Because the serum creatinine level rose from 3.1 to 5.7 mg/lOO ml on June 4, another cellular rejection was suspected, and the administration of intravenous methylprednisolone was continued for a total of 57 g. However, the serum creatinine returned only to 4.6 mg/lOO ml.
MICROANGIOPATHIC HEMOLYTIC ANEMIA-MAGALHAES
A cystogram obtained on June 26 because of an abrupt decrease in urine output to 250 ml/day showed that the bladder was displaced nearly to the umbilicus by an extravesical fluid collection. Aspiration of lymph from the paravesical space was performed on June 27 with relief of the obstruction. However, there were two recurrences of the lymphocele that required aspiration on December 7, 1972, and finally surgical drainage on April 16, 1973, for complete resolution. On the most recent examination on August 16, 1973, serum creatinine was 2.2 mg/iOO ml and creatinine clearance 50.8 ml/min. The clinical condition of the patient was good; he was completely asymptomatic and working full time. It should be emphasized that during the patient’s treatment with this very large total dose of intravenous methylprednisolone, numerous precautions were instituted to avoid the potential hazards of such therapy: (1) Serum glucose, osmolality and electrolytes were frequently measured; (2) stools were tested for occult blood, particularly during the period of anticoagulation; (3) roentgenograms of the chest as well as cultures of blood and urine were obtained even in the absence of fever because of the capacity of such large doses of intravenous methylprednisolone to suppress fever and clinical findings of infection; (4) daily intravenous methylprednisolone dosage schedules of 1 or 2 g were interrupted at 3 to 4 day intervals to reevaluate carefully the patient’s status. Cushingoid changes were remarkably slight and there was no roentgenologic evidence of aseptic necrosis.
ET AL.
SPECIAL STUDIES
Figure 3. Photomicrograph of the peripheral blood showing anisocflosis, poikilocytosis and fragmentation of red cells. Wright’s stain; original magnification X 800, reduced by 10 per cent.
Erythrocyte. A red cell survival study with Cr5’ showed a T1/2 survival of 19 days (normal: 25 to 30 days) on May 15, 1972. The results of mechanical fragility, osmotic fragility, incubated osmotic fragility and autohemolysis tests with and without added glucose were normal on May 17, 1972. Fibrinogen. The patient’s fibrinogen, measured on May 9, 1972, by a modification of the method of Ratnoff and Menzie [9], was 254 mg/lOO ml of plasma. It contained no detectable polymeric forms by ultracentrifuge analysis (
ROBERTO L. MAGALHAES,
M.D.
WILLIAM E. BRAUN, M.D. RALPH A. STRAFFON,
M.D.
GEORGE C. HOFFMAN, M.D. JOHN R. SHAINOFF, Ph.D. GARY OSBORNE SHARAD D. DEODHAR, M.D., Ph.D. Cleveland, Ohio
The development of microangiopathic hemolytlc anemia after renal transplantation in a 17 year old white boy is reported, and the literature is reviewed. In this patient microangiopathic hemolytic anemia developed 6 weeks after renal transplantation during a second episode of rejection. Light, fluorescence and electron microscopy demonstrated the renal vascular lesion associated with this syndrome. In contrast to the other four previously reported cases of microangiopathic hemolytic anemia associated with renal allotransplantation, this patient had complete resolution of the microangiopathic hemolytic anemia with heparin therapy and improved allograft function, presumably with diminution of the vascular lesion. He survived a complicated early period after renal transplantation and has shown no recurrence of microangiopathic hemolytic anemia in the 16 months since transplantation. Special red blood cell and fibrinogen studies are discussed. The term
From the Renal Transplantation Service and the Departments of Hypertension and Nephrology, Urology, and Clinical Pathology, and the Division of Research, The Cleveland Clinic Foundation, Cleveland, Ohio. This study was supported in part by Contract NO1 Al 22536, National Institutes of Health, U.S. Department of Health, Education and Welfare. Requests for reprints should be addressed to Dr. William E. Braun. Department of Hypertension and Nephrology, The Cleveland Clinic Foundation, 900 Euclid Avenue, Cleveland, Ohio 44106. Manuscript accepted May 6, 1974. Present address: Rua Fonte da Saudade 256, ap. 302, 20,000 Rio de Janeiro, Brazil. l
662
June 1975
microangiopathic hemolytic anemia was first suggested by Symmers [I] in 1952 as a more appropriate term for thrombotic thrombocytopenic purpura, and in the following year Monroe and Strauss [2] suggested that the pathologic process in the small blood vessels in thrombotic thrombocytopenic purpura might be responsible for the hemolysis of the red blood cells. These latter investigators observed fragmented red cells in the peripheral blood of two patients with intravascular hemolysis caused by thrombotic thrombocytopenic purpura. After noting the fragmented red blood cells within the blood vessels and tissues from a patient with microangiopathic hemolytic anemia who died, they further suggested that the partially occluded blood vessels might be the actual site of red cell fragmentation and destruction. This concept was further elaborated upon by Brain [3,4] in extensive reviews of microangiopathic hemolytic anemia. Since Ehrlich’s [5] description in 1891 of fragmented erythrocytes in patients with pernicious anemia, numerous conditions have been associated with microangiopathic hemolytic anemia; they include malignant hypertension [3,4,6], periarteritis nodosa [3], systemic lupus erythematosus [3], thrombotic thrombocytopenic purpura [3,4,6], ulcerative colitis [6], preeclampsia and eclampsia [4], purpura fulminans [4], cavernous hemangioma [ 41, postpartum state [ 41, metastatic malignancy [3,4,6], hemolytic-uremic syndrome [4], glomerulonephritis [ 31, renal cortical necrosis [3] and renal allotransplantation [7,8].
The American Journal of Medicine
Volume 58
MICROANGIOPATHIC HEMOLYTIC ANEMIA-MAGALHAES
We describe a renal allograft recipient in whom microangiopathic hemolytic anemia developed in the course of rejection early in the post-transplant period. Treatment of the rejection with heparin was associated with resolution of the hemolytic anemia and improvement in renal function. Despite a further complication, a lymphocele, the patient has continued to have good renal function, and the hemolytic anemia has not recurred during a follow-up period of 18 months.
CASE REPORT A 17 year old white boy had scarlet fever and occasional sore throats at age 6 for which he was treated with penicillin. Asymptomatic proteinuria developed at age 12. His sister, one of three siblings, had scarlet fever at age 9 and died at age 18 of an unknown type of nephritis. The patient underwent a percutaneous renal biopsy on March 11, 1969, which showed diffuse sclerosing glomerulonephritis. Except for hypertension he was asymptomatic until July 28, 197 1, when oliguria developed. Because of pulmonary edema, anuria, hyperkalemia and ventricular tachycardia, peritoneal dialysis was begun on July 30, 197 1; his condition improved. Hemodialysis was started on December 9, 1971, and bilateral nephrectomies were performed on March 1, 1972. Splenectomy was not performed. The patient received a renal allograft from his mother on March 28 (Figure 1). Immunosuppressive therapy consisted of 2 mg/kg of prednisone, 5 mg/kg of azathioprine for one dose and then 2 mglkg thereafter. In addition, on the day of transplantation, the patient was given 1 g of methylprednisolone intravenously. The kidney functioned well and by the 3rd postoperative day the blood urea nitrogen had decreased to 16 mgli00 ml and the serum creatinine to 1.4 mg/lOO ml. The temperature rose to 10l°F on the 2nd postoperative day. Because blood, urine and sputum cultures were sterile, and because there was no clinical or roentgenologic source of infection, the persistence of the fever, along with a decrease in urine output and the development of hypertension, suggested rejection. Treatment with intravenous methylprednisolone was started. An intravenous pyelogram on April 6 showed no abnormality. A renal angiogram on April 10 showed a normal clearance time of the dye (2 seconds) and no vascular abnormalities. A renal biopsy performed on April 11, after a total of 10 g of intravenous methylprednisolone had been given, showed interstitial edema and mononuclear cell infiltrates around the peritubular capillaries and diffusely throughout the interstitium. Although no vascular changes were seen by light microscopy, immunofluorescence showed focal deposits of immunoglobulins G (IgG) and M (IgM), and complement in the small arteries. The serum creatinine reached a peak of 4.1 mg/ 100 ml and the blood urea nitrogen 116 mg/lOO ml on April 12. After a total of 18 g of intravenous methylprednisolone had been given, the serum creatinine and blood urea nitrogen decreased to 1.4 and 47 mg/lOO ml, respectively, on April 23, and the patient was discharged
ET AL.
from the hospital. He was receiving 60 mg of prednisone and 75 mg of azathioprine at that time. Because of swelling of the allograft, temperature of 103 OF and an increase in serum creatinine to 3.2 mg/iOO ml, the patient was readmitted to the hospital on April 28. Intravenous methylprednisolone therapy was instituted and another renal biopsy was performed on May 2. Up to the time of this renal biopsy, a total of 26 g of intravenous methylprednisolone had been given. The glomeruli showed focal necrosis, fibrinous deposits and swollen endothelial cells causing occlusion of capillary lumens. The small blood vessels showed areas of fibrinoid necrosis, markedly swollen endothelial cells, intraluminal fibrinous deposits and mononuclear cells infiltrating the vessel walls. Immunofluorescence showed focal deposition of IgM and the third component of complement (PtC) in blood vessels, tu-
v#ttl(s
Clinical course after renal transplantation showing hematologic and renal function changes, and therapy. The dose of methylprednisolone is cumulative.
Flgure
June 1975
1.
The Amerlcan Journalof Medlclne Volume 55
863
MlCROANGlOfATtiC
HEMOLYTC
ANEMIA-MAGALHAES
ET AL.
Figure 2. Left, note the large electron dense deposits (0) which have narrowed the vascular lumen (L) to an irregular, eccentric channel. En = endothelial cell; SM = smooth muscle cell. Right, the capillary lumen (L) is markedly narrowed by deposition of platelets (P) and electron dense material (0) in the subendothelial regions. Also, there is marked fusion and flattening of epithelial foot processes. Note the irregular shaped erythrocyte (Er) which appears to be trapped in the lumen and impaled on an endothelial protuberance or “spike” (S). BM = basement membrane; Ep = epithelial cell. Two per cent osmium tetroxlde; original magnification X 7,153 (left) and X 4,546 (right), reduced by 25 per cent.
bular basement membrane and Bowman’s capsule. Electron microscopic findings are presented in Figure 2. Because of the generalized softness and purplish color of the allograft and difficulty in controlling bleeding from the biopsy site, anticoagulation was not instituted immediately. The serum creatinine and blood urea nitrogen levels rose to 10.5 and 175 mg/iOO ml, respectively, on May 5, when the first of two hemodialyses was performed. Since there was no bleeding from the biopsy site during heparinization for dialysis, heparin therapy, 10,000 units daily, was instituted on May 5. At that time, the platelet count was 165,000/mm3, the total bilirubin 0.7 mg/lOO ml and the lactic dehydrogenase 215 Wroblewski units (normal: 30 to 120 units). On May 10, a reticulocyte count of 19 per cent was noted in association with a fall in the hemoglobin level from 8.4 to 6.6 g/100 ml, absent serum haptoglobin, plas-
064
June 1975
The American Journal of Medicine
Volume 59
ma hemoglobin of 15.6 mg/lOO ml (normal: 1 to 5 mg/lOO ml), urine hemosidarin, deformed shapes of the red cells, and red cell fragments, indicating microangiopathic hemolytic anemia (Figure 3). Antinuclear factor, three lupus erythematosus preparations, the glucose-6-phosphate dehydrogenase screening test, and direct and indirect Coombs’ test were negative. Stools had no occult blood. On May 11, the dose of heparin was increased to 16,000 units daily and continued for a total of 36 days when Coumadine therapy was started. By May 21, the hemoglobin level had risen to 10.3 g/ 100 ml, and the reticulocyte count had decreased to 4.1 per cent on May 28. No transfusions were given. Because the serum creatinine level rose from 3.1 to 5.7 mg/lOO ml on June 4, another cellular rejection was suspected, and the administration of intravenous methylprednisolone was continued for a total of 57 g. However, the serum creatinine returned only to 4.6 mg/lOO ml.
MICROANGIOPATHIC HEMOLYTIC ANEMIA-MAGALHAES
A cystogram obtained on June 26 because of an abrupt decrease in urine output to 250 ml/day showed that the bladder was displaced nearly to the umbilicus by an extravesical fluid collection. Aspiration of lymph from the paravesical space was performed on June 27 with relief of the obstruction. However, there were two recurrences of the lymphocele that required aspiration on December 7, 1972, and finally surgical drainage on April 16, 1973, for complete resolution. On the most recent examination on August 16, 1973, serum creatinine was 2.2 mg/iOO ml and creatinine clearance 50.8 ml/min. The clinical condition of the patient was good; he was completely asymptomatic and working full time. It should be emphasized that during the patient’s treatment with this very large total dose of intravenous methylprednisolone, numerous precautions were instituted to avoid the potential hazards of such therapy: (1) Serum glucose, osmolality and electrolytes were frequently measured; (2) stools were tested for occult blood, particularly during the period of anticoagulation; (3) roentgenograms of the chest as well as cultures of blood and urine were obtained even in the absence of fever because of the capacity of such large doses of intravenous methylprednisolone to suppress fever and clinical findings of infection; (4) daily intravenous methylprednisolone dosage schedules of 1 or 2 g were interrupted at 3 to 4 day intervals to reevaluate carefully the patient’s status. Cushingoid changes were remarkably slight and there was no roentgenologic evidence of aseptic necrosis.
ET AL.
SPECIAL STUDIES
Figure 3. Photomicrograph of the peripheral blood showing anisocflosis, poikilocytosis and fragmentation of red cells. Wright’s stain; original magnification X 800, reduced by 10 per cent.
Erythrocyte. A red cell survival study with Cr5’ showed a T1/2 survival of 19 days (normal: 25 to 30 days) on May 15, 1972. The results of mechanical fragility, osmotic fragility, incubated osmotic fragility and autohemolysis tests with and without added glucose were normal on May 17, 1972. Fibrinogen. The patient’s fibrinogen, measured on May 9, 1972, by a modification of the method of Ratnoff and Menzie [9], was 254 mg/lOO ml of plasma. It contained no detectable polymeric forms by ultracentrifuge analysis (
