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.
Case summary: 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.
Discussion: 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.