Haematologica, Vol 92, Issue 8, 1029-1036 doi:10.3324/haematol.10733
Copyright © 2007 by Ferrata Storti Foundation
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Bone Marrow Failure

Red cell aplasia and autoimmune hemolytic anemia following immunosuppression with alemtuzumab, mycophenolate, and daclizumab in pancreas transplant recipients

Milena Elimelakh, Vanessa Dayton, Katharine S. Park, Angelika C. Gruessner, David Sutherland, Robert B. Howe, Mark T. Reding, Ted Eastlund, Jo-Anne van Burik, Timothy P. Singleton, Rainer W. Gruessner, Nigel S. Key

From the Departments of Medicine, Surgery, and Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, MN, USA

Correspondence: Milena Elimelakh, MD, MMC 480, Mayo Building 420 Delaware St S.E., Minneapolis, MN 55455, USA. E-mail: elime002{at}umn.edu

Background and Objectives: Acquired red cell aplasia (RCA) is a rare disorder and can be either idiopathic or associated with certain diseases, pregnancy, or drugs. In exceptionally rare cases, it has been reported to co-exist with other autoimmune cytopenias. We report a high incidence of RCA and autoimmune hemolytic anemia (AIHA) in pancreas transplant recipients on alemtuzumab-based maintenance therapy.

Design and Methods: Between February 2003 and July 2005, 357 pancreas transplant recipients were treated with immunosuppressive regimens containing the lymphocyte-depleting antibody alemtuzumab, the T-cell activation inhibitor daclizumab, and the anti-metabolite mycophenolate mofetil (MMF). We retrospectively reviewed medical records, blood bank data and bone marrow biopsy specimens of patients with a Transplant Information Services database diagnosis of RCA and AIHA from February 2003 to November 2005.

Results: Severe RCA, AIHA, and idiopathic thrombocytopenic purpura (ITP) occurred independently or in combination, in 20 out of 357 (5.6%) pancreas transplant recipients, 12 to 24 months following the initiation of the aforementioned immunosuppressive regimens. Severe opportunistic infections developed late in 14/20 (70%) of these patients. Atypical morphologic features, including variable dysgranulopoiesis, variable megakaryocytic hyperplasia with normal or low peripheral platelet counts, and atypical lymphoid aggregates were found in bone marrow trephine sections of 11 patients in whom the diagnosis of RCA was made.

Interpretation and Conclusions: We hypothesize that the combination of alemtuzumab, daclizumab and MMF can result in immune dysregulation thereby permitting autoantibody formation. Because the use of these three immune suppressants is becoming increasingly common, it is important to recognize the severe hematologic complications that can arise.

Key words: red cell aplasia, AIHA, ITP, MMF, alemtuzumab, daclizumab.




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