SEVERE THROMBOCYTOPENIA DUE TO ELECTRON-BEAM POLYSULFONE DIALYZER MEMBRANE REACTION MASQUERADING AS CHRONIC IMMUNE THROMBOCYTOPENIC PURPURA

ABSTRACT

SESSION TITLE Critical Thinking SESSION TYPE Case Reports PRESENTED ON 10/19/2022 0915 am - 1015 am INTRODUCTION: We describe a case of severe thrombocytopenia due to reaction with an electron-beam sterilized polysulfone (PS) membrane in a patient with a previous diagnosis of reported chronic immune thrombocytopenic purpura (ITP). This phenomenon has been previously described but is rarely reported. Electron-beam (e-beam) sterilized PS membranes are classically more biocompatible than cellulose-based membranes but adverse reactions may occur as demonstrated in our case. CASE PRESENTATION An 84-year-old woman with ESRD on hemodialysis (HD) and reported chronic ITP refractory to glucocorticoids with severe thrombocytopenia at baseline presented for evaluation of chest pain. She was incidentally found to have severe thrombocytopenia and treated with high dose glucocorticoids with minimal improvement in her thrombocytopenia and transitioned to chronic glucocorticoid taper. She had a severe chronic thrombocytopenia despite glucocorticoids which was suspected to be chronic ITP and diagnosed after initiation of outpatient HD. HD was held the first few days of her admission. She was found to have multifocal pneumonia due to SARS-CoV-2 infection. She developed progressive hypoxemic respiratory failure requiring intubation with sepsis treated with vancomycin & piperacillin-tazobactam. BAL revealed ESBL Escherichia coli & transitioned to ertapenem. She developed recurrent thrombocytopenia following HD and her PLT would improve between HD sessions. Evaluation of usual culprits of thrombocytopenia was unrevealing. Reaction to the PS membrane was suspected and a cellulose-based dialyzer membrane was used instead for subsequent sessions of HD with recovery of the platelet counts to normal. The remainder of her course was significant for tracheostomy with ventilator dependence and surrogate pursued compassionate care. DISCUSSION: We describe an interesting case of severe thrombocytopenia due to PS membrane reaction which was previously labeled as chronic ITP. Usual culprits such as pseudothrombocytopenia, HIT, HIV, HCV, hypersplenism, alcohol use, nutritional deficiencies, and rheumatologic disease were excluded. Synthetic membranes like PS-membranes are traditionally regarded as more biocompatible but filter reactions are described [1]. It is hypothesized that e-beam radiation may affect dialyzer membrane integrity or structure, or produce intermediary products which may cause platelet activation, aggregation, and adsorption, and therefore thrombocytopenia [2]. There is a high prevalence of thrombocytopenia among critically ill patients undergoing HD [3]. CONCLUSIONS: Thrombocytopenia due to PS dialyzer membrane is a rarely reported phenomenon and may be underrecognized in critically ill patients. This entity should be considered in the differential diagnosis of patients undergoing HD who develop thrombocytopenia. Early recognition may reduce incidence of bleeding and need for blood products in these patients. Reference #1 Golli-Bennour EE, Kouidhi B, Dey M et al. Cytotoxic effects exerted by polyarylsulfone dialyser membranes depend on different sterilization processes. Int Urol Nephrol 2011;43 483–490. Reference #2 Batalini F, Aleixo GF, Maoz A, Sarosiek S. Haemodialysis-associated thrombocytopenia interactions among the immune system, membranes and sterilisation methods. BMJ Case Rep. 2019 Sep 4;12(9)e229594. doi 10.1136/bcr-2019-229594. PMID 31488440;PMCID PMC6731774. Reference #3 Griffin BR, Jovanovich A, You Z, Palevsky P, Faubel S, Jalal D. Effects of Baseline Thrombocytopenia and Platelet Decrease Following Renal Replacement Therapy Initiation in Patients With Severe Acute Kidney Injury. Crit Care Med. 2019;47(4)e325-e331. doi10.1097/CCM.0000000000003598 DISCLOSURES No relevant relationships by Adefemi Adeyemo No relevant relationships by Zachary Chandler No relevant relationships by Bijal Patel No relevant relationships by Vandana Seeram