title: Use of romiplostim in a hemodialysis patient with primary immune thrombocytopenia.
abstract: OBJECTIVE
  To present the case of a patient with primary immune thrombocytopenia (ITP), renal impairment, and chronic hepatitis C virus (HCV) infection who was treated with platelet transfusions, intravenous immunoglobulin (IVIG), corticosteroids, eltrombopag, rituximab, and romiplostim in an attempt to raise platelet counts to a clinically acceptable level.
  
  
  METHODS
  A 71-year-old man with end-stage renal disease (ESRD) was on maintenance hemodialysis and had long-term diabetes mellitus, chronic obstructive pulmonary disease, and other comorbidities. He was admitted with epistaxis, severe thrombocytopenia, and a platelet count of 4 × 10(9)/L. Platelet transfusions, treatment with IVIG, corticosteroids, eltrombopag, and rituximab resulted in transient and inadequate increases in platelet counts. Further bleeding manifestations, including epistaxis, melena, hematomas, and ecchymotic patches prompted treatment with blood product concentrates and a higher dose of eltrombopag, resulting in a further lack of clinical response. After 6 weeks of failed treatment attempts, initiation of weekly treatment with romiplostim 5 μg/kg resulted in rapid stabilization (within a week) of platelet counts in the range of 200 × 10(9)/L. The patient was discharged, with subsequent dose adjustment of weekly romiplostim treatment to 2.5 μg/kg, continued hemodialysis, and a return to normal daily activities.
  
  
  CONCLUSIONS
  The primary clinical concern in this elderly patient with multiple comorbidities was to lower the bleeding risk associated with consistent thrombocytopenia. Despite the lack of clinical data to support the efficacy and safety of romiplostim in patients with ITP and renal impairment, stimulation of platelet production with romiplostim was a reasonable approach in view of the bleeding risk and following nonresponse to treatment with corticosteroids, IVIG, eltrombopag, and rituximab. To our knowledge, this case represents the first successful use of romiplostim to manage primary ITP in the presence of ESRD and concurrent chronic HCV infection in a patient on hemodialysis.
  
  
  CONCLUSIONS
  Romiplostim appears to be a viable option for treatment of ITP in a patient with ESRD and chronic HCV infection following nonresponse to treatment with corticosteroids, IVIG, eltrombopag, and rituximab.
authors.affiliation: Hematology Department, Amiri Hospital, Kuwait. cbc8@hotmail.com
authors.forename: Hassan
authors.initials: H
authors.lastname: Al-Jafar
authors.forename: Aristoteles
authors.initials: A
authors.lastname: Giagounidis
authors.forename: Kamel
authors.initials: K
authors.lastname: El-Rashaid
authors.forename: Masouma
authors.initials: M
authors.lastname: Al-Ali
authors.forename: Abbas A
authors.initials: AA
authors.lastname: Hakim
mesh_terms: D000368:Aged; D003920:Diabetes Mellitus / Q000188:drug therapy; D019698:Hepatitis C, Chronic / Q000188:drug therapy; D006801:Humans; D007676:Kidney Failure, Chronic / Q000188:drug therapy; D008297:Male; D029424:Pulmonary Disease, Chronic Obstructive / Q000188:drug therapy; D011961:Receptors, Fc / Q000627:therapeutic use*; D053628:Receptors, Thrombopoietin / Q000819:agonists*; D011993:Recombinant Fusion Proteins / Q000627:therapeutic use*; D013921:Thrombocytopenia / Q000188:drug therapy*; D013926:Thrombopoietin / Q000627:therapeutic use*
chemical_list: D011961:Receptors, Fc; D053628:Receptors, Thrombopoietin; D011993:Recombinant Fusion Proteins; D013926:Thrombopoietin; C488777:romiplostim