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Abstract: FR-PO560

Erythropoietin Stimulating Agent (ESA)-Resistant Vitamin B6 Deficiency Anemia in a Pediatric Patient on Hemodialysis

Session Information

Category: Trainee Case Report

  • 701 Dialysis: Hemodialysis and Frequent Dialysis


  • Patel, Sagar, LSU Health Sciences Center, Shreveport, Louisiana, United States
  • Goswick, Leah E., LSU Health Sciences Center, Shreveport, Louisiana, United States
  • Jeroudi, Majed, LSU Health Sciences Center, Shreveport, Louisiana, United States
  • Baliga, Radhakrishna, LSU Health Sciences Center, Shreveport, Louisiana, United States

Vitamin B6 is a water soluble vitamin, the active form of which is Pyridoxal 5’-phosphate, that functions as a coenzyme of erythroid specific 5-aminolevulinate synthase (ALAS2) which is involved in the synthesis of heme. Vitamin B6 deficiency is often associated with inflammation as observed in chronic kidney disease, particularly those requiring dialysis. Administration of an ESA has also been shown to be associated with increased erythrocyte consumption of vitamin B6. We report here a pediatric patient who developed an ESA resistant anemia that significantly improved following vitamin B6 supplementation.

Case Description

16-year-old African American male with end stage renal disease secondary to obstructive uropathy, on chronic hemodialysis, experienced a decrease in his hemoglobin over a 3-month period from 11 to 6.5 g/dL, while receiving darbepoietin alfa (ESA) [0.9mcg/kg/week] intravenously for one month. His transferrin saturation was 41%, ferritin level 706 [80-388] ng/mL, mean corpuscular volume (MCV) 87 [78- 98] fL. His corrected reticulocytes count was 2.3% [0.2-1.8%]. Additional laboratory data included the following: Direct antiglobulin testing and stool for occult blood were negative; Vitamin B12, 635 [193-986] pg/ml; folate, 8.4 [3.1-17.5] ng/mL; copper, 1413 [665-1480] mcg/l; zinc, 77 [60-120] mcg/dL and Ceruloplasmin, 31.4 [15-30] mg/dL. PTH was elevated at 258 [9-69] pg/ml. Vitamin B6 level was low at 1.2 [5.3-46.7] ug/L. Bone marrow biopsy was normocellular (65%) with erythroid hyperplasia and rare dyserythropoiesis. Prussian blue staining showed increased iron storage. Supplemental Vitamin B6 (100mg daily) was initiated, at which time his hemoglobin was 7.3 g/dL. Three months later, his hemoglobin was 11.6 g/dL with transferrin saturation of 18%.


Vitamin B6 clearance is increased with standard hemodialysis and a further 50% increase in vitamin clearance is noted when receiving high flux high efficiency hemodialysis as seen in our patient. Vitamin B6 deficiency anemia should be considered in any pediatric patient on high flux hemodialysis who is not responding to standard ESA and iron therapy.