Cleveland Clinic Journal of MedicineHematologic Complications after Kidney and Pancreas Transplant in a Patient with Chronic Myeloid Leukemia

Complex Interplay of Autoimmunity, Organ Transplant, and Myeloid Neoplasms in Hematologic Complications

This article examines the case of a 35-year-old woman who, following a simultaneous pancreas and kidney transplant, developed significant hematologic complications. Highlighting a rare intersection of chronic myeloid leukemia (CML), autoimmunity, and post-transplant complications, this study underscores the necessity of vigilant monitoring and a comprehensive differential diagnosis to navigate the multifaceted nature of post-transplant hematologic disorders.

Key Points:

• The patient, with a history of type 1 diabetes and end-stage renal disease, underwent a simultaneous pancreas and kidney transplant, followed by induction and maintenance immunosuppression.
• Post-transplant, the patient exhibited hyperleukocytosis, prompting a series of diagnostic tests, including peripheral blood smear and bone marrow biopsy, which eventually led to a diagnosis of chronic-phase CML.
• The presence of neutrophilia, eosinophilia, and basophilia, alongside a high BCR-ABL1/ABL1 ratio, was critical in confirming CML, differentiating it from other potential causes of leukocytosis.
• The patient’s autoimmunity background, specifically type 1 diabetes, may have contributed to the pathogenesis of CML, highlighting an association between autoimmunity and myeloproliferative neoplasms.
• The onset of thrombocytopenia post-CML diagnosis raised differential diagnoses including drug-induced thrombocytopenia and immune thrombocytopenia (ITP), with the latter confirmed by bone marrow biopsy and treatment response.
• Introduction of dasatinib, a tyrosine kinase inhibitor, led to a molecular response in CML, yet subsequent thrombocytopenia necessitated its discontinuation, illustrating the delicate balance in managing CML treatment and its side effects.
• The development of Evans syndrome, characterized by simultaneous or sequential occurrence of autoimmune hemolytic anemia and ITP, added complexity to the patient’s condition, underscoring the need for a nuanced approach to post-transplant hematologic anomalies.
• This case demonstrates the necessity of a broad, detailed evaluation including differential counts and peripheral blood smears in patients with unexplained leukocytosis post-transplant, advocating for a holistic understanding of the patient’s medical history and treatment nuances.

In this 2020 report, the incidence of non-Hodgkin lymphoma was 60% higher among patients with all autoimmune diseases as compared to the general population. A total of 21 specific autoimmune diseases showed a positive association with subsequent non-Hodgkin lymphoma, and none of them showed a negative association.

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