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논문분류	춘계학술대회 초록집
제목	Anemia due to Myelodysplastic Syndrome Induced by Azathioprine and Allopurinol in Kidney Transplant Patient: A Case Report
저자	Aryan Yohanes Djojo
출판정보	2024; 2024(1):
키워드
초록	A 79-year-old female presented to our hospital with anemia in August 2019. She has been a kidney transplant recipient since 19 years ago. The patient was taking azathioprine 25 mg once daily, tacrolimus 1 mg (morning) and 0.5 mg (evening). Other medication was allopurinol 100 mg once daily. Laboratory examinations revealed hemoglobin level of 6.3 g/dl, leukocyte 2,000/ ul platelet 103,000 / ul, LDH 251 u/l, total bilirubin 0.55 mg/dl, direct bilirubin 0.24 mg/dl, reticulocyte of 1.5%. Serum creatinine varied from 1.2 to 1.5 mg/dl and tacrolimus level was 5 ng/ml. One week later, patient had palpitation due to low hemoglobin level (5 g/dl) and was transfused with packed red cell to hemoglobin 10 g/dl. Azathioprine was discontinued and replaced with mycophenolate. On September 2019, patient had palpitation again and hemoglobin level was 8.9 g/dl. Patient received washed erythrocyte transfusion, and allopurinol was discontinued. On October 2019, bone marrow examination revealed myelodysplastic syndrome (MDS) with multi-lineage dysplasia. After discontinuing azathioprine and allopurinol, the hemoglobin level showed improvement (10.5 g/dl at three months and 11.1 mg/dl at seven months after discontinuation). Hemolytic anemia was excluded by normal bilirubin, LDH, and reticulocyte. Graft rejection was excluded by stable level of creatinine. The patient fulfilled the criteria of MDS. We discontinued the azathioprine and allopurinol. There was one case report of MDS in kidney transplant patient receiving azathioprine.1 The mechanism of how azathioprine induce MDS is not well understood. It could be related to chromosomal break and other cytogenetic abnormalities and remitted after discontinuation of azathioprine. Several reports showed allopurinol could induce aplastic anemia but not MDS.2,3 Madrazo L et al report anemia induced by azathioprine and potentiated by concurrent use of allopurinol though not in a kidney transplant recipient.4 The patient showed improvement after discontinuation of the 2 drugs.
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