Ann Hematol (2002) 81:158160

DOI 10.1007/s00277-001-0425-4

C A S E R E P O RT

C. Frohn W.J. Jabs L. Fricke S. Goerg

Hemolytic anemia after kidney transplantation:

case report and differential diagnosis

Received: 14 May 2001 / Accepted: 13 December 2001 / Published online: 30 January 2002
Springer-Verlag 2002

Abstract A 58-year-old woman presented with hemolysis and thrombocytopenia 2 weeks after receiving a kidney graft. Hemolytic uremic syndrome was initially suspected, because in addition to hematological changes the
graft function was missing. Unexpectedly, the results of
the direct antiglobulin test became positive (4+), which
is not normally observed in the hemolytic uremic syndrome. Differentiation of the eluted antibodies revealed
anti-rhesus D specificity, which had to be interpreted either as an autoantibody of patients origin or, hypothetically, as a graft versus host antibody of donor origin.
Gm- and Km allotyping of these antibodies demonstrated a pattern which differed from the patients but was
identical to that of the kidney donor. Therefore hemolysis could be explained unambiguously by graft versus
host antibodies. Whether the thrombocytopenia was
also due to an immune process was not clear, although
some evidence favors this hypothesis. Immunosuppressive treatment remained unchanged and several red
blood cell transfusions were necessary before reactivity
of the direct antiglobulin test diminished and became
negative 7 weeks after kidney transplantation. The occurrence of hemolysis in the early posttransplantation
period should thus draw attention to the possibility of
graft versus host antibodies directed against red cells.
Concomitant thrombocytopenia may occur. Donor
screening for irregular erythrocyte antibodies should be
performed whenever solid organ transplantation is intended.
Keywords Kidney transplantation Thrombocytopenia
Hemolytic anemia Hemolytic uremic syndrome Evans
syndrome
C. Frohn () S. Goerg
Institute of Immunology and Transfusion Medicine,
University of Lbeck School of Medicine, Lbeck, Germany
e-mail: frohn@immu.mu-luebeck.de
Tel.: +49-451-5003384, Fax: +49-451-5002857
W.J. Jabs L. Fricke
1st Department of Internal Medicine,
University of Lbeck School of Medicine, Lbeck, Germany

Introduction
A case of immune hemolytic anemia with positive results on the direct antiglobulin test (DAT) may be either
an independent disease or associated with several underlying disorders, for instance, hematological malignancies. Moreover, a variety of drugs may induce a hemolysis that presents with a positive DAT finding. Differential diagnosis of hemolysis in the context of kidney
transplantation can be quite difficult since hemolysis
may be drug induced by neoantigen/immune-complex
formation or by cyclosporin A induced immune dysregulation [5]. Additionally, hemolysis might indicate hemolytic-uremic syndrome (HUS) or Evans syndrome [3], although the latter is not commonly associated with a positive DAT finding. If the patient requires blood transfusions, alloantibodies must be ruled out. Anemia as a result of the surgical procedure or a bleeding disorder
complicates the diagnosis. Here we report a case of severe DAT-positive immune hemolytic anemia due to anti-rhesus D red blood cell (RBC) antibodies originating
from donor B-cells transferred with the transplanted kidney.

Case report
A 58-year-old woman (A Rh D+) received her third kidney graft
from a male donor (A Rh D). The underlying diagnosis leading to
renal failure was unclear; the patient suffered from chronic hepatitis C. The immunosuppressive regimen included tacrolimus, azathioprine, and steroids. Postoperative bleeding required surgical
treatment; the subsequent anemia and thrombocytopenia were initially considered as normal consequences of this complication.
Unexpectedly, the hemoglobin levels and platelet counts did not
stabilize after the bleeding had been stopped. Decreased haptoglobin levels and increased levels of free hemoglobin, lactic dehydrogenase, total and indirect bilirubin then revealed a hemolytic origin of the anemia. At the same time a missing graft function was
recognized. Hemoglobin, platelet counts, lactic dehydrogenase,
and DAT during the hospital period are presented in Fig. 1.
Since the triad of hemolysis, thrombocytopenia, and missing
graft function exists, a diagnosis of HUS was initially suspected.
Increased vascular resistance in the graft was diagnosed by duplex

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Fig. 1 Time course

Table 1 Gm/Km typing of the donor, recipient (free antibody in

the serum) and recipient (eluted antibodies). The Gm 1 and Km
loci are not informative; Gm 2 typing demonstrates the donor origin of the eluted antibodies. The specificity of eluted antibody was
anti-D

Table 2 Differential diagnosis hemolytic uremic syndrome

(HUS), graft-versus-host immune hemolytic anemia (GvH-IHA),
autoimmune hemolytic anemia (AIHA) and relevant clinical and
laboratory findings
AIHA GvH-IHA HUS Case

Gm 1
Gm 2
Km

Donor

Recipient

Eluted antibodies

+
+

sonography, and this observation supported the diagnosis. Although no fragmented erythrocytes were observed, plasma exchange therapy was initiated for managing the suspected HUS.
Since treatment did not induce graft function, a needle biopsy of
the kidney was performed which did not show microthrombes,
thus excluding the diagnosis of HUS. Concurrently a positive DAT
result was obtained, and monospecific sera demonstrated RBCbound antibodies of the IgG type. This was surprising since erythrocyte destruction in HUS is not immune mediated. Elution of the
RBC-bound antibodies was performed several times; anti-D specificity was clearly demontrated using a standard panel with 14 test
cells. Free antibody was never detected in the serum. We wondered whether this antibody was produced by the patients own Bcells (by definition an autoantibody considering the patients D+
rhesus typing) or by B-cells transplanted with the graft thus representing an graft-versus-host constellation.
Before the development of the anti-D antibody 7 U packed
RBC and two fresh frozen plasmas were given. All blood products
are routinely irradiated at 35 Gy for patients awaiting transplantation in our hospital; all included blood donations tested negative
for irregular erythrocyte antibodies.
The Gm and Km allotypes are heterogeneous amino acid sequences in certain segments of the IgG heavy chain and light
chain, respectively, being expressed uniformly in all IgG molecules of one individual without interfering with their specificity or
activity. Allotyping was performed as described previously [9]. As
shown in Table 1 we could demonstrate the donors allotype of the
eluted antibodies. A reevaluation of his medical history revealed
an anti-D antibody, probably resulting from multiple erythrocyte
transfusions with rhesus D+ units during the acute treatment phase
after his fatal accident. No elevated antibody load on peripheral
platelets was observed by either platelet immune fluorescence test
or platelet immune fluorescence test as an explanation for the decreased platelet counts observed. However, it must be considered
that only 70% of immune thrombocytopenias concur with positive
tests for peripheral platelet bound IgG [7]. No anti-nuclear antibodies, which would have indicated a systemic autoimmune process had they been present, were detected by indirect immunofluorescence. Immunosuppressive treatment remained unchanged, and

Hemolysis
Thrombocytopenia
Fragmentocytes
Positive DAT
Specific antibody elutable
Missing graft function
Microthrombes in renal biopsy
Increased renal vascular resistance

+
(+)

+
?

+
+

+
+
+

+
+
+

+
+

+
+
+

several RBC transfusions were necessary before the reactivity of

DAT diminished and became negative 7 weeks after kidney transplantation. After this time, the hematological changes disappeared
and the graft functionality commenced.

Discussion
This case clearly demonstrates donor-derived RBC antibodies as a rare cause of immune hemolysis and the consequences of misinterpreting the combination of hemolysis and renal dysfunction as HUS (Table 2). The development of such antibodies after solid organ transplantation has been suspected in several cases. Most of the antibodies were naturally occurring AB0 antibodies [1, 11,
12, 17, 19, 20, 21] nevertheless, some rhesus antibodies
have also been reported [5, 8, 10, 14, 15, 16, 18, 22].
The origin of these rhesus antibodies was determined directly in only a single case [22]; moreover, a helpful
complete typing of donors rhesus antigens was omitted
in the majority of cases. Thus in many reports there is
some ambiguity as to whether the antibodies should be
classified as autoimmune (possibly provoked by cyclosporin-induced immune dysregulation) or graft versus
host (produced by passenger lymphocytes transferred
with the grafted organ). In the case presented here the
latter explanation was confirmed unequivocally by serological methods. Furthermore the antibodies are not derived from blood transfusions, as all included units are -

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irradiated to suppress lymphocyte proliferation and because all blood donations are confirmed by tests to be
negative for serologically detectable RBC alloantibodies.
A point of major concern is the thrombocytopenia in
this patient. It can be explained in part by bleeding episodes leading to RBC transfusions. However, these
events cannot adequately account for the intensity and
time course observed. The immunosuppressive drugs (tacrolimus and steroids, no cyclosporin) probably did not
cause thrombocytopenia since no such side effects have
ever been reported with tacrolimus [13]. Alternatively,
the immune process leading to erythrocyte destruction
may also have involved the platelets. This hypothesis is
strongly favored by the temporary increase in platelet
counts after plasmapheresis. Since rhesus antigens are not
present on platelets, the observed anti-D antibodies cannot mediate the platelet destruction directly. However,
platelet destruction by Kidd antibodies, which cannot
bind to platelets in combination with autoimmune hemolytic anemia either, has been described [4, 6]. Such a
combination of autoimmune hemolytic anemia and
thrombocytopenia is generally termed Evans syndrome
and has also been reported in a kidney transplant recipient [3]. In all these cases as well as in our own case an innocent bystander mechanism involving the platelets must
be considered for explaining the low platelet counts.
Preformed RBC antibodies have been reported in the
majority of cases with graft-versus-host immune hemolytic anemia. The frequency of irregular, i.e., non-AB0,
antibodies in cadaveric organ donors might be higher
than in the general population (1.4% in our hospital), because many of them are heavily transfused during their
final hospital treatment. Thus a donor screening for irregular RBC antibodies should be performed and communicated to the treating physician whenever an organ
transplantation is planned.
Acknowledgements The authors thank T. Quandt and J. Lckhof
for excellent technical assistance.

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