Anaemia in a renal allograft recipient: an unusual cause.

Defining anaemia as haemoglobin level less than 13 g/dL for men and less than 12 g/dL for women, the investigators of The Transplant European Study on Anemia Management (TRESAM) reported the prevalence of anaemia in renal transplant recipients as 38.6 % at enrolment [1]. The list of causes of anaemia in renal transplant recipients is long one [2]. We are presenting a report on our findings in a renal transplant recipient who was on azathioprine. In this patient, it was found that anaemia was due to a different cause. The patient on whom the present case study is based was a 65 years old, when he came to us. He had undergone renal transplantation 20 years earlier. His primary kidney disease was presumed to be chronic interstitial nephritis ? end-stage renal disease. His mother was the donor. He was initially on cyclosporine, prednisolone, and azathioprine. After 4 years, cyclosporine was tapered completely. When the patient came to us, he was on prednisolone 10 mg/d and azathioprine 150 mg/d. He presented to us with complaints of fever with chill and rigor of 5 days duration. He had history of malaise and easy fatigability of 5 months duration and breathlessness of 1 month duration. He also had history of progressive numbness of his fingers and toes ascending to mid-shin and mid-forearm over 1 year. He is a vegetarian. On examination, it was found that he was febrile, with 102 F, blood pressure was 110/75 mm Hg, pulse rate was 110 bpm. He was found to be anaemic with no lymphadenopathy. Cardiovascular, respiratory, and abdomen examination was unremarkable. Central nervous system examination revealed that power in distal limb muscles was 3/5 and in proximal limb muscles was 4/5, ankle jerks were absent and knee jerks were sluggish. Bilateral, symmetrical impaired touch, vibratory and proprioception up to knee joints was also revealed. There was unsteadiness in gait. Investigations are presented in the Table 1. The peripheral smear and bone marrow suggested myelodysplasia. The patient had been on azathioprine. It was replaced by everolimus, 0.5 mg bid. He was transfused two units of packed cells and prescribed ferrous fumarate, 152 mg three times a day. As vitamin B12 and folic acid levels were within normal limits, they were not prescribed. The patient was examined after 2 weeks. Malaise, fatigability, and breathlessness were still present. The unsteadiness of gait worsened. His investigations revealed that haemoglobin: 5.5 g/dL, total leucocyte count: 1,400/ cu mm, platelet count: 55,000/cu mm, and serum creatinine: 1.5 mg/dL. Serum copper and serum ceruloplasmin levels were sent for estimation. The total serum copper was 20.5 lg/dL (reference range 63.7–140.12 lg/dL), and serum ceruloplasmin was 8.5 lg/dL (reference range 18–35 lg/dL). He was supplemented with copper-rich foods. He was advised to include spinach, peppermint, tomatoes, sunflower seeds, and ginger in his diet. He was transfused with two units of blood and was discharged. After 2 weeks, haemoglobin level was 9.8 g/dL, total R. Ram (&) Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati 517502, India e-mail: ram_5_1999@yahoo.com