Evans Syndrome in Renal Transplantation: Correlation between Drops in Platelet and Red Blood Cell Counts and Rejection

Dr. Claudio Campieri, Nephrology Institute, S. Orsola University Hospital, V. Massarenti, 9, I-40138 Bologna (Italy) Dear Sir, Immune thrombocytopenic purpura (ITP) can occur in patients with kidney transplantation in whom a ‘drop’ in platelet count can be the only clinical expression of this disease [1]. ITP can be associated with autoimmune hemolytic anemia in Evans syndrome [2]. In a transplanted patient with ITP we detected features of Evans syndrome and found a highly significant correlation between the increase in serum creatinine associated with rejection on the one hand, and platelet and RBC drops on the other hand. A 59-year-old woman who had undergone cadaveric renal transplantation in January 1979 presented a serum creatinine of 2 mg/dl while under therapy with azathio-prine 50 mg/day and prednisone 25 mg/day. In October 1995, an immune thrombocytopenic crisis with a platelet count of 80,000/ mm3 was diagnosed in the presence of direct and indirect antiplatelet antibodies. A previous drop in platelet count (50,000/mm3) dated back to June 1987 during an episode of rejection (serum creatinine up to 2.3 mg/ dl). By that time, RBC count was 2,910,000/ mm3 with a Hb of 9 g%. A cross-match was positive for HLA-A33 antigen. Enhanced antirejection therapy resolved the episode of rejection (creatinine 1.1 mg%) and increased the platelets (up to 180,000-220,000/mm3) as well as RBCs (up to 3,870,000/mm3) within 5 days. In August 1987, a thrombophlebitis of the right leg led to hospital admission associated with thrombocytopenia (60,000/ mm3) and autoimmune hemolytic anemia (3,125,000/mm3) with a positive direct and indirect Coombs’ test. In this patient we analyzed the serum creatinine values and platelet and RBC counts during 3 hospital admissions for rejection episodes and 5 hospital admissions not related to rejection (ureteral stenting, acute gastroenteritis, pulmonary infection, cyclospo-rine toxicity), as shown in table 1. Asymptomatic drops in platelet count (80,000-120,000 platelets/mm3) and hemolytic anemia ( < 3,000,000/mm3) have been detected during hospital admissions for rejection, and an enhancement in immunosup-pressive therapy either resolved the rejection or increased platelet and RBC count.