Kidney Week

Abstract: FR-PO1010

Against All Odds: First Report of Concurrent Anti-Erythropoietin (EPO) Antibody-Mediated Pure Red Cell Aplasia and Heparin-Induced Thrombocytopenia Type 2 Successfully Managed in a Patient on Dialysis

Session Information

• Hemodialysis: Clinical Challenges, Patient-Centered Outcomes, and Quality of Life
  October 23, 2026 | Location: Exhibit Hall A, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Dialysis

• 801 Dialysis: Hemodialysis and Frequent Dialysis

Authors

• Pascoal, Felipe, Centro Brasiliense de Nefrologia Ltda, Brasília, DF, Brazil

Felipe Pascoal, MD

• Pascoal, Pedro Guimaraes, Centro Brasiliense de Nefrologia Ltda, Brasília, DF, Brazil

Pedro Guimaraes Pascoal, MD

• Pascoal, Mateus, Centro Brasiliense de Nefrologia Ltda, Brasília, DF, Brazil

Mateus Pascoal, MEd

• Lauar, Juliane, Centro Brasiliense de Nefrologia Ltda, Brasília, DF, Brazil

Juliane Lauar, MD

• Pascoal, Istenio, Centro Brasiliense de Nefrologia Ltda, Brasília, DF, Brazil

Istenio Pascoal, MD

Introduction

Anti-EPO antibody-mediated pure red cell aplasia (PRCA) and heparin-induced thrombocytopenia (HIT) type II are rare complications in dialysis patients and their coexistence has not been previously reported. We present the first case of concurrent PRCA and HIT type II, successfully managed with cyclophosphamide, apixaban and predilution online hemodiafiltration (OL-HDF).

Case Description

An 81-year-old male with advanced CKD initiated postdilution OL-HDF with unfractionated heparin in March 2025. In two months, platelets dropped from 141k to 60k/µL. Elevated anti-PF4 and partial arteriovenous fistula thrombosis confirmed HIT type II. Heparin was suspended and platelets recovered, but frequent circuit clotting prompted apixaban 2.5 mg BID and transition to predilution OL-HDF with saline flushes, resolving all events. Meanwhile, hemoglobin declined below 10 g/dL despite EPO escalation to 24,000 IU/week, with suppressed reticulocytes (0.23%). Anti-EPO was positive and bone marrow biopsy confirmed erythroid hypoplasia. Cyclosporine with prednisone was not tolerated, but IV cyclophosphamide 5 mg/kg weekly, followed by oral 50 mg daily, normalized reticulocytes within two months, reversing transfusion reliance. Presently, the patient remains off heparin and EPO, free of thrombotic or transfusion events (graph shown).

Discussion

To our knowledge, this is the first case of concomitant anti-EPO PRCA and HIT type II. Each alone is rare: PRCA at 0.002-0.03/1,000 patient-years on ESA and HIT type II in 0.1-5% of heparin-exposed patients, making their convergence exceptional. This report highlights cyclophosphamide as an effective salvage therapy for anti-EPO PRCA, while predilution OL-HDF with apixaban provides a safe heparin-free platform addressing HIT hypercoagulability. When rare complications converge, it is the willingness to look beyond protocols and tailor every layer of care that ultimately turns a challenging scenario into a successful outcome.