Saturday, February 4, 2017

Consult Rounds: Thrombocytopenia in ESRD

Thrombocytopenia in a hemodialysis patient can be from multiple reasons

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The top reasons we encounter are:


The most common is heparin and HIT.

A nice review of HIT in the renal patient is here

The other causes can be related to other medical illness not ESRD related. An important but rare cause that can be associated with dialysis associated with thrombocytopenia is a dialyzer reaction. A large systemic evaluation done in Canada suggested that the prevalence of thrombocytopenia associated with dialysis was due to the use of electron beam dialyzers( optiflux) rather than irradiated sterilized dialyzers ( others).  This suggests a relationship of use of the dialyzer sterilization technique causing this.  Exposure to e-beam radiation may change membrane integrity, structure, or physical properties of the dialyzer and could plausibly lead to platelet activation, aggregation, or adsorption and subsequent thrombocytopenia. E-beam sterilization has become a popular method of membrane sterilization recently, because it potentially allows a more focused and precisely delivered dose of sterilization toward the dialyzer membrane. A case report in AJKD had highlighted low platelets as a side effect of dialyzer reaction. Certain membranes due to the many types of hydroxyl groups contained can lead to an active complement system( the older dialyzers).  The degree of complement activation determines the biocompatibility of the membrane. A prior post in RFN also had discussed this phenomenon.
This review from Hemodialysis International is a great one for all to review.

If the patient is inpatient, we might notice that the day after dialysis the platelets drop from 150 to 50 perhaps and then rebound and then again the drop happens on the next set of labs. It is very likely that we are missing this phenomenon on the outpatient and there is ongoing endothelial damage happening chronically due to some of these membranes.  We only check monthly labs in US.  A true incidence of this phenomenon is hard to determine.  

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