Diagnostic Challenges of ESA-Resistant Anemia with MDSLike Marrow Abnormalities: The Importance of Excluding Reversible Causes

Abstract

Introduction. Erythropoiesis-stimulating agent (ESA) hypo
responsiveness in elderly patients undergoing maintenance 
hemodialysis is frequently multifactorial and may be difficult to 
distinguish from anemia associated with primary bone marrow 
disorders. 
Case Report. We report an 89-year-old man with ESA-resistant, 
transfusion-dependent anemia. Bone marrow examination 
demonstrated dysplastic megakaryocytic changes and isolated loss 
of the Y chromosome, raising concern for an underlying clonal 
marrow disorder. However, serum copper and ceruloplasmin 
levels showed no evidence of copper deficiency, and no zinc 
excess was identified. Hematologic improvement occurred during 
a period in which pneumonia and volume overload improved; 
however, luspatercept had previously been administered while 
ESA and intravenous iron therapy were continued, precluding 
attribution of the response to any single intervention. 
Conclusions. This case highlights the importance of integrating 
MDS-like marrow findings with systematic and longitudinal 
assessment of potentially reversible contributors to ESA hypo
responsiveness, because marrow abnormalities and reversible 
causes of impaired erythropoiesis may coexist in elderly 
hemodialysis patients.