Refractory Post-transplant Erythrocytosis in a Renal Transplant Recipient: A Case Report.

Background: Post-transplant erythrocytosis (PTE) is a well-recognized complication occurring in approximately 8-15 % of renal transplant recipients. It is commonly managed with renin-angiotensin system (RAS) inhibitors, including angiotensin receptor blockers (ARBs). However, a subset of patients may be refractory to standard pharmacologic therapy. Case presentation: We report the case of a 57-year-old male kidney transplant recipient who developed persistent erythrocytosis despite treatment with an ARB. The patient remained symptomatic with elevated hematocrit levels, prompting consideration of alternative management strategies. Management and outcome: Given the inadequate response to RAS blockade, therapeutic phlebotomy was initiated. The patient tolerated the procedure well, and phlebotomy was effective in achieving long-term hematocrit control and symptom relief. No significant complications were observed during follow-up. Conclusion: This case underscores the need for individualized management in patients with refractory PTE. It demonstrates the safe and effective use of therapeutic phlebotomy when pharmacologic interventions fail. The variability in treatment response suggests a need for flexible hematocrit targets and emphasizes monitoring of clinical symptoms in addition to laboratory values. Further research is needed to establish optimal treatment strategies and identify predictors of resistance to RAS blockade.