Kidney transplantation in patients with severe aplastic anemia: A case series of four patients bridging to tolerance or hematologic recovery

Severe aplastic anemia (SAA) is a bone marrow failure syndrome characterized by pancytopenia and hypocellular marrow. When accompanied by end-stage kidney disease (ESKD), it presents a significant therapeutic challenge. Although allogeneic hematopoietic stem cell transplantation (HSCT) is the definitive treatment for SAA and kidney transplantation (KT) is the optimal therapy for ESKD, the ideal sequencing and strategy for performing both procedures remain unclear. We report successful outcomes in 4 patients with concurrent SAA and ESKD managed using a KT-first approach. All patients demonstrated immediate graft function without surgical complications, and no episodes of acute rejection were observed within the first year posttransplant. Two patients subsequently underwent HSCT from the same donor used for KT, approximately 3 months after KT. Both achieved hematologic remission and were eventually able to discontinue all immunosuppressive medications. Remarkably, the other 2 patients experienced spontaneous hematologic improvement and no longer required HSCT. These findings suggest that the KT-first approach is both feasible and safe, serving not only as a bridge to curative HSCT but also, in select cases, as a potential standalone therapy for SAA. This case series provides preliminary evidence supporting the role of the KT-first strategy in patients with coexisting SAA and ESKD.