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Kidney disease following hematopoietic cell transplantation

Chirag Parikh, MD, PhD
Robert S Negrin, MD
Section Editor
Paul M Palevsky, MD
Deputy Editor
Albert Q Lam, MD


Hematopoietic cell transplantation (HCT) is the only cure for a variety of hematologic and oncologic diseases. However, it has been associated with the development of both acute and chronic kidney failure [1]. (See "Preparative regimens for hematopoietic cell transplantation".)

The term "hematopoietic cell transplantation" will be used throughout this review as a general term to cover transplantation of progenitor cells from any source (eg, bone marrow, peripheral blood, cord blood). Otherwise, the source of such cells will be specified (eg, autologous peripheral blood progenitor cell transplantation). (See "Sources of hematopoietic stem cells".)

Although the requirement for dialysis following HCT is relatively uncommon (in the range of 2 to 5 percent), it is generally associated with an extremely poor prognosis. However, acute kidney injury (AKI), as defined by doubling or smaller increases in the serum creatinine concentration, is common, approaching 50 to 60 percent in several reports. There are a variety of causes of AKI following HCT and several risk factors that are associated with chronic kidney disease (CKD). In the majority of patients, renal dysfunction is temporary and returns to baseline; however, adjusting medications to avoid further damage is common.

This topic will review the epidemiology and causes of kidney injury following HCT other than sepsis or drug-induced acute tubular necrosis or tumor lysis syndrome. These include hepatic sinusoidal obstructive syndrome (SOS, formerly known as veno-occlusive disease), hemolytic-uremic syndrome or thrombotic microangiopathy, and calcineurin inhibitor nephrotoxicity. The technique and other complications associated with HCT are discussed separately. (See "Preparative regimens for hematopoietic cell transplantation" and "Hematopoietic support after hematopoietic cell transplantation".)


The epidemiology and risk factors of kidney injury following hematopoietic cell transplantation (HCT) vary with the different types of regimens associated with HCT:


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Literature review current through: Sep 2016. | This topic last updated: Mar 28, 2016.
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  1. Cohen EP. Renal failure after bone-marrow transplantation. Lancet 2001; 357:6.
  2. Zager RA, O'Quigley J, Zager BK, et al. Acute renal failure following bone marrow transplantation: a retrospective study of 272 patients. Am J Kidney Dis 1989; 13:210.
  3. Zager RA. Acute renal failure in the setting of bone marrow transplantation. Kidney Int 1994; 46:1443.
  4. Parikh CR, McSweeney PA, Korular D, et al. Renal dysfunction in allogeneic hematopoietic cell transplantation. Kidney Int 2002; 62:566.
  5. Hingorani SR, Guthrie K, Batchelder A, et al. Acute renal failure after myeloablative hematopoietic cell transplant: incidence and risk factors. Kidney Int 2005; 67:272.
  6. Gooley TA, Chien JW, Pergam SA, et al. Reduced mortality after allogeneic hematopoietic-cell transplantation. N Engl J Med 2010; 363:2091.
  7. Parikh CR, Schrier RW, Storer B, et al. Comparison of ARF after myeloablative and nonmyeloablative hematopoietic cell transplantation. Am J Kidney Dis 2005; 45:502.
  8. Parikh CR, Sandmaier BM, Storb RF, et al. Acute renal failure after nonmyeloablative hematopoietic cell transplantation. J Am Soc Nephrol 2004; 15:1868.
  9. Parikh CR, McSweeney P, Schrier RW. Acute renal failure independently predicts mortality after myeloablative allogeneic hematopoietic cell transplant. Kidney Int 2005; 67:1999.
  10. Ando M, Mori J, Ohashi K, et al. A comparative assessment of the RIFLE, AKIN and conventional criteria for acute kidney injury after hematopoietic SCT. Bone Marrow Transplant 2010; 45:1427.
  11. Hingorani S. Chronic kidney disease in long-term survivors of hematopoietic cell transplantation: epidemiology, pathogenesis, and treatment. J Am Soc Nephrol 2006; 17:1995.
  12. Kal HB, van Kempen-Harteveld ML. Renal dysfunction after total body irradiation: dose-effect relationship. Int J Radiat Oncol Biol Phys 2006; 65:1228.
  13. Ellis MJ, Parikh CR, Inrig JK, et al. Chronic kidney disease after hematopoietic cell transplantation: a systematic review. Am J Transplant 2008; 8:2378.
  14. Guinan EC, Tarbell NJ, Niemeyer CM, et al. Intravascular hemolysis and renal insufficiency after bone marrow transplantation. Blood 1988; 72:451.
  15. Cohen EP, Lawton CA, Moulder JE, et al. Clinical course of late-onset bone marrow transplant nephropathy. Nephron 1993; 64:626.
  16. Cohen EP, Lawton CA, Moulder JE. Bone marrow transplant nephropathy: radiation nephritis revisited. Nephron 1995; 70:217.
  17. Lawton CA, Cohen EP, Barber-Derus SW, et al. Late renal dysfunction in adult survivors of bone marrow transplantation. Cancer 1991; 67:2795.
  18. Leblond V, Sutton L, Jacquiaud C, et al. Evaluation of renal function in 60 long-term survivors of bone marrow transplantation. J Am Soc Nephrol 1995; 6:1661.
  19. Borg M, Hughes T, Horvath N, et al. Renal toxicity after total body irradiation. Int J Radiat Oncol Biol Phys 2002; 54:1165.
  20. Cheng JC, Schultheiss TE, Wong JY. Impact of drug therapy, radiation dose, and dose rate on renal toxicity following bone marrow transplantation. Int J Radiat Oncol Biol Phys 2008; 71:1436.
  21. Weiss AS, Sandmaier BM, Storer B, et al. Chronic kidney disease following non-myeloablative hematopoietic cell transplantation. Am J Transplant 2006; 6:89.
  22. Humphreys BD, Soiffer RJ, Magee CC. Renal failure associated with cancer and its treatment: an update. J Am Soc Nephrol 2005; 16:151.
  23. Parikh CR, Coca SG. Acute renal failure in hematopoietic cell transplantation. Kidney Int 2006; 69:430.
  24. McDonald GB, Hinds MS, Fisher LD, et al. Veno-occlusive disease of the liver and multiorgan failure after bone marrow transplantation: a cohort study of 355 patients. Ann Intern Med 1993; 118:255.
  25. Fink JC, Cooper MA, Burkhart KM, et al. Marked enzymuria after bone marrow transplantation: a correlate of veno-occlusive disease-induced "hepatorenal syndrome". J Am Soc Nephrol 1995; 6:1655.
  26. Sniecinski IJ, Oien L, Petz LD, Blume KG. Immunohematologic consequences of major ABO-mismatched bone marrow transplantation. Transplantation 1988; 45:530.
  27. Changsirikulchai S, Myerson D, Guthrie KA, et al. Renal thrombotic microangiopathy after hematopoietic cell transplant: role of GVHD in pathogenesis. Clin J Am Soc Nephrol 2009; 4:345.
  28. Jodele S, Licht C, Goebel J, et al. Abnormalities in the alternative pathway of complement in children with hematopoietic stem cell transplant-associated thrombotic microangiopathy. Blood 2013; 122:2003.
  29. Paquette RL, Tran L, Landaw EM. Thrombotic microangiopathy following allogeneic bone marrow transplantation is associated with intensive graft-versus-host disease prophylaxis. Bone Marrow Transplant 1998; 22:351.
  30. Antignac C, Gubler MC, Leverger G, et al. Delayed renal failure with extensive mesangiolysis following bone marrow transplantation. Kidney Int 1989; 35:1336.
  31. Loomis LJ, Aronson AJ, Rudinsky R, Spargo BH. Hemolytic uremic syndrome following bone marrow transplantation: a case report and review of the literature. Am J Kidney Dis 1989; 14:324.
  32. Rabinowe SN, Soiffer RJ, Tarbell NJ, et al. Hemolytic-uremic syndrome following bone marrow transplantation in adults for hematologic malignancies. Blood 1991; 77:1837.
  33. Cruz DN, Perazella MA, Mahnensmith RL. Bone marrow transplant nephropathy: a case report and review of the literature. J Am Soc Nephrol 1997; 8:166.
  34. Ruutu T, Hermans J, Niederwieser D, et al. Thrombotic thrombocytopenic purpura after allogeneic stem cell transplantation: a survey of the European Group for Blood and Marrow Transplantation (EBMT). Br J Haematol 2002; 118:1112.
  35. George JN, Li X, McMinn JR, et al. Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome following allogeneic HPC transplantation: a diagnostic dilemma. Transfusion 2004; 44:294.
  36. Siami K, Kojouri K, Swisher KK, et al. Thrombotic microangiopathy after allogeneic hematopoietic stem cell transplantation: an autopsy study. Transplantation 2008; 85:22.
  37. Fuge R, Bird JM, Fraser A, et al. The clinical features, risk factors and outcome of thrombotic thrombocytopenic purpura occurring after bone marrow transplantation. Br J Haematol 2001; 113:58.
  38. Lawton CA, Barber-Derus SW, Murray KJ, et al. Influence of renal shielding on the incidence of late renal dysfunction associated with T-lymphocyte deplete bone marrow transplantation in adult patients. Int J Radiat Oncol Biol Phys 1992; 23:681.
  39. Cohen EP, Robbins ME. Radiation nephropathy. Semin Nephrol 2003; 23:486.
  40. Hébert MJ, Fish D, Madore F, et al. Mesangiolysis associated with bone marrow transplantation: new insights on possible etiogenic factors. Am J Kidney Dis 1994; 23:882.
  41. Grigg A, Clouston D. Disseminated fungal infection and early onset microangiopathy after allogeneic bone marrow transplantation. Bone Marrow Transplant 1995; 15:795.
  42. Maslo C, Peraldi MN, Desenclos JC, et al. Thrombotic microangiopathy and cytomegalovirus disease in patients infected with human immunodeficiency virus. Clin Infect Dis 1997; 24:350.
  43. Imai H, Oyama Y, Miura AB, et al. Hematopoietic cell transplantation-related nephropathy in Japan. Am J Kidney Dis 2000; 36:474.
  44. El-Seisi S, Gupta R, Clase CM, et al. Renal pathology at autopsy in patients who died after hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2003; 9:683.
  45. Atkinson K, Biggs JC, Hayes J, et al. Cyclosporin A associated nephrotoxicity in the first 100 days after allogeneic bone marrow transplantation: three distinct syndromes. Br J Haematol 1983; 54:59.
  46. Elliott MA, Nichols WL Jr, Plumhoff EA, et al. Posttransplantation thrombotic thrombocytopenic purpura: a single-center experience and a contemporary review. Mayo Clin Proc 2003; 78:421.
  47. Moulder JE, Fish BL. Influence of nephrotoxic drugs on the late renal toxicity associated with bone marrow transplant conditioning regimens. Int J Radiat Oncol Biol Phys 1991; 20:333.
  48. Wolff D, Wilhelm S, Hahn J, et al. Replacement of calcineurin inhibitors with daclizumab in patients with transplantation-associated microangiopathy or renal insufficiency associated with graft-versus-host disease. Bone Marrow Transplant 2006; 38:445.
  49. Au WY, Ma ES, Lee TL, et al. Successful treatment of thrombotic microangiopathy after haematopoietic stem cell transplantation with rituximab. Br J Haematol 2007; 137:475.
  50. Silva VA, Frei-Lahr D, Brown RA, Herzig GP. Plasma exchange and vincristine in the treatment of hemolytic uremic syndrome/thrombotic thrombocytopenic purpura associated with bone marrow transplantation. J Clin Apher 1991; 6:16.
  51. Cohen EP. Radiation nephropathy after bone marrow transplantation. Kidney Int 2000; 58:903.
  52. Moulder JE, Fish BL, Cohen EP. Treatment of radiation nephropathy with ACE inhibitors. Int J Radiat Oncol Biol Phys 1993; 27:93.
  53. Cohen EP, Moulder JE, Fish BL, Hill P. Prophylaxis of experimental bone marrow transplant nephropathy. J Lab Clin Med 1994; 124:371.
  54. Paller MS. Bone marrow transplantation nephropathy. J Lab Clin Med 1994; 124:315.
  55. Dieterle A, Gratwohl A, Nizze H, et al. Chronic cyclosporine-associated nephrotoxicity in bone marrow transplant patients. Transplantation 1990; 49:1093.
  56. Ruiz-Arguelles GJ, Gomez-Almaguer D. Nephrotic syndrome after non-myeloablative stem cell transplantation. Br J Haematol 2006; 132:801.
  57. Srinivasan R, Balow JE, Sabnis S, et al. Nephrotic syndrome: an under-recognised immune-mediated complication of non-myeloablative allogeneic haematopoietic cell transplantation. Br J Haematol 2005; 131:74.
  58. Brukamp K, Doyle AM, Bloom RD, et al. Nephrotic syndrome after hematopoietic cell transplantation: do glomerular lesions represent renal graft-versus-host disease? Clin J Am Soc Nephrol 2006; 1:685.
  59. Reddy P, Johnson K, Uberti JP, et al. Nephrotic syndrome associated with chronic graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2006; 38:351.
  60. Kawakami K, Watanabe Y, Mukai K, et al. Nephrotic syndrome with extensive mesangiolysis as a clinical manifestation of chronic graft-versus-host disease (GVHD). Int J Hematol 2005; 82:270.
  61. Suehiro T, Masutani K, Yokoyama M, et al. Diffuse proliferative glomerulonephritis after bone marrow transplantation. Clin Nephrol 2002; 58:231.
  62. Kemper MJ, Güngör T, Halter J, et al. Favorable long-term outcome of nephrotic syndrome after allogeneic hematopoietic stem cell transplantation. Clin Nephrol 2007; 67:5.
  63. Terrier B, Delmas Y, Hummel A, et al. Post-allogeneic haematopoietic stem cell transplantation membranous nephropathy: clinical presentation, outcome and pathogenic aspects. Nephrol Dial Transplant 2007; 22:1369.
  64. Stevenson WS, Nankivell BJ, Hertzberg MS. Nephrotic syndrome after stem cell transplantation. Clin Transplant 2005; 19:141.
  65. Sayegh MH, Fine NA, Smith JL, et al. Immunologic tolerance to renal allografts after bone marrow transplants from the same donors. Ann Intern Med 1991; 114:954.
  66. Butcher JA, Hariharan S, Adams MB, et al. Renal transplantation for end-stage renal disease following bone marrow transplantation: a report of six cases, with and without immunosuppression. Clin Transplant 1999; 13:330.
  67. Scandling JD, Busque S, Dejbakhsh-Jones S, et al. Tolerance and chimerism after renal and hematopoietic-cell transplantation. N Engl J Med 2008; 358:362.