title: Severe sirolimus-related inflammatory state anemia in an HIV+ liver transplant patient with calcineurin inhibitor renal insufficiency: a case report.
abstract: Although multifactorial anemia is common following orthotopic liver transplantation (OLT), the late introduction of sirolimus (SRL) has been associated with high rates of anemia, whose pathogenic mechanisms have not been fully studied. Herein we have described a case of severe anemia in an HIV+ OLT patient who was switched from calcineurin inhibitors (CNI) to SRL due to severe nephrotoxicity. After 22 weeks of SRL, hemoglobin levels dropped 4 g/dL to a nadir of 6.5 g/dL. After discarding other causes for anemia, we concluded that it displayed the features of anemia of a chronic inflammatory state (ACIS): decreased mean corpuscular volume (MCV), low serum iron despite high ferritinemia, and elevated fibrinogen and C-reactive protein (CRP) levels. SRL trough levels were never above the therapeutic range. After blood transfusions and erythropoietin (EPO) use, SRL was maintained within the lower range of therapeutic levels, with significant improvement in renal function. As described among kidney transplant recipients, SRL-related anemia in this HIV+ patient with CNI nephrotoxicity after OLT showed features of ACIS. Blood transfusions and EPO use allowed SRL maintenance.
authors.affiliation: Service of Infectious Diseases, Hospital Ramón y Cajal, Madrid, Spain. amoreno.hrc@salud.madrid.org
authors.forename: A
authors.initials: A
authors.lastname: Moreno
authors.forename: R
authors.initials: R
authors.lastname: Bárcena
authors.forename: M
authors.initials: M
authors.lastname: García-Gonzalez
authors.forename: F
authors.initials: F
authors.lastname: García-Hoz
authors.forename: C
authors.initials: C
authors.lastname: Quereda
authors.forename: J L
authors.initials: JL
authors.lastname: Casado
authors.forename: M J
authors.initials: MJ
authors.lastname: Pérez-Elías
authors.forename: J
authors.initials: J
authors.lastname: Fortún
authors.forename: J
authors.initials: J
authors.lastname: Nuño
authors.forename: I
authors.initials: I
authors.lastname: Arranz
authors.forename: S
authors.initials: S
authors.lastname: Moreno
mesh_terms: D048868:Adaptor Proteins, Signal Transducing; D000740:Anemia / Q000139:chemically induced* / Q000150:complications / Q000628:therapy; D001803:Blood Transfusion; D002097:C-Reactive Protein / Q000378:metabolism; D019703:Calcineurin / Q000172:deficiency*; D004921:Erythropoietin / Q000627:therapeutic use; D006679:HIV Seropositivity; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects*; D007249:Inflammation / Q000209:etiology; D007501:Iron / Q000097:blood; D016031:Liver Transplantation / Q000276:immunology*; D008297:Male; D008875:Middle Aged; D051437:Renal Insufficiency / Q000139:chemically induced / Q000150:complications; D020123:Sirolimus / Q000009:adverse effects*; D014168:Transferrin / Q000378:metabolism
chemical_list: D048868:Adaptor Proteins, Signal Transducing; C491861:CABIN1 protein, human; D007166:Immunosuppressive Agents; D014168:Transferrin; D004921:Erythropoietin; D002097:C-Reactive Protein; D007501:Iron; D019703:Calcineurin; D020123:Sirolimus