title: Management of refractory essential thrombocythemia with anagrelide in a patient undergoing hemodialysis.
abstract: BACKGROUND
  Management of essential thrombocythemia (ET) in high-risk patients is difficult because high platelet numbers can lead to vascular occlusive events and bleeding. Therapeutic interventions in ET are limited to hydroxyurea and anagrelide; however, in Europe, anagrelide is contraindicated in patients with chronic renal disease.
  
  
  OBJECTIVE
  The aim of this case report was to describe the use of anagrelide in a patient with ET and renal impairment.
  
  
  METHODS
  A 73-year-old white female patient with severe renal impairment who was diagnosed with ET was receiving treatment with hydroxyurea 1 g/d since 2001. At this time she was also receiving aspirin 80 mg/d; calcium carbonate 1 g/d; pravastatin 40 mg/d; folic acid 5 mg/d; furosemide 40 mg/d; cetirizine 10 mg/d; erythropoietin 10,000 U once monthly; a vitamin B complex, 1 tablet a day; and iron tablets 105 mg/d. In February 2007, because her white blood cell count fell to 2.1 x 10(9)/L, myelodepression was suspected and hydroxyurea was stopped. This led to enhanced platelet levels and the introduction of anagrelide at an initial dose of 0.5 mg/d that was steadily increased to 2.5 mg/d. All other treatments were continued with some dosage adjustments. Sodium bicarbonate 1 g/d and vitamin D were added to her regimen. After 18 months of anagrelide treatment, a sudden but moderate fall of platelets to 142 x 10(3)/microL with severe anemia (hemoglobin, 6.5 g/dL) was observed. The patient had anemia since 2004, but the condition worsened due to bleeding related to an ulcer at the cecal valve. The patient refused blood and platelet transfusions and surgical intervention for religious reasons. Because of hemodynamic instability, she was admitted to the intensive care unit in December 2008 and died 24 hours after admission.
  
  
  CONCLUSIONS
  We report a case of ET and chronic renal failure treated with anagrelide and low-dose aspirin in a patient who did not receive transfusion and surgical intervention due to religious reasons, and had a fatal outcome.
authors.affiliation: Nephrology and Dialysis Clinic, Université Libre de Brussels, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium. maria.mesquita@chu-brugmann.be
authors.forename: Maria do Carmo Filomena
authors.initials: Mdo C
authors.lastname: Mesquita
authors.forename: Eugénie Bakoto
authors.initials: EB
authors.lastname: Sol
authors.forename: Marianne
authors.initials: M
authors.lastname: Malarme
authors.forename: Denis
authors.initials: D
authors.lastname: Noubouossie
authors.forename: Anne Claire
authors.initials: AC
authors.lastname: Demulder
mesh_terms: D000368:Aged; D001241:Aspirin / Q000627:therapeutic use; D001772:Blood Cell Count; D001774:Blood Chemical Analysis; D001803:Blood Transfusion; D004351:Drug Resistance; D004921:Erythropoietin / Q000627:therapeutic use; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D006918:Hydroxyurea / Q000627:therapeutic use; D033221:Jehovah's Witnesses; D007676:Kidney Failure, Chronic / Q000150:complications / Q000188:drug therapy; D007677:Kidney Function Tests; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D010976:Platelet Count; D011799:Quinazolines / Q000627:therapeutic use*; D011994:Recombinant Proteins; D006435:Renal Dialysis; D013920:Thrombocythemia, Essential / Q000188:drug therapy*
chemical_list: D010975:Platelet Aggregation Inhibitors; D011799:Quinazolines; D011994:Recombinant Proteins; D004921:Erythropoietin; C021139:anagrelide; D001241:Aspirin; D006918:Hydroxyurea