Phlebotomy for Polycythemia Associated with Acquired Cystic Renal Disease in a Patient on Hemodialysis

Fernando Liaño, MD, Department of Nephrology, Hospital Ramón y Cajal, Carr. Colmenar, Km. 9,100, E-28034 Madrid (Spain), Dear Sir, Human erythropoietin (EPO) deficiency is considered a decisive factor in the development of anemia of chronic renal failure [1]. The presence of normal hemoglobin (Hb) and hematocrit (Ht) levels is not frequent in patients on hemodialysis [2] and levels above the normal range are exceedingly rare, usually associated with policythemia vera, lung or liver disease, malignant tumors, nephroan-giosclerosis and acquired cystic kidney disease (ACKD) [1,3-5]. We report a patient on hemodialysis who developed ACKD and polycythemia who needed phlebotomy to mantain Ht levels within an adequate range. A 61-year-old male nonsmoker presented in June 1980 with hypertension, edema, heavy proteinuria and microscopic hematuria. Renal biopsy showed advanced glomerular sclerosis and interstitial fibrosis with angio-sclerosis at the small vessel level. Renal size and outline were normal on tomography. Several months later, terminal renal failure made periodic hemodialysis necessary. Hb was 10.1 g/dl and Ht 30.3%. Bone marrow aspirate showed alterations compatible with anemia secondary to chronic renal failure. During the next years, the patient did well on our hemodialysis program except for several episodes of supraventricular tachycardia finally diagnosed as Wolff-Parkinson-White syndrome. In October 1989, he suffered the breaking of his arterio-venous fistula due to local infection. In January 1990, Hb was 16.5 g/dl and Ht 54%, and a therapeutic phlebotomy (400 ml) was indicated. Since August 1990, Hb has been between 15 and 17 g/dl and Ht between 48 and 50%. Liver and pulmonary function tests were normal, as was α-fetoprotein and carcinoem-bryonic antigen. Abdominal computed tomography showed bilateral renal cysts and he was diagnosed having ACKD. Serum EPO levels were progressively elevated (fig. 1). In an attempt to lower them, oral theophylline (400 mg/day) was started, but intense headache obliged us to withdraw this drug. In December 1990, Hb was 18.5 g/dl and Ht 56.5%, and therapeutic phlebotomy was necessary. The hematologic evolution is depicted in figure 1. During the first 10 years on periodic hemodialysis, our patient maintained Hb levels below normal values, as it is the rule in these populations [2]. In the last 2 years, slow but progressive Ht elevation was noted and finally, exceedingly high Ht levels required therapeutic phlebotomy. Extrarenal causes of erythrocytosis were excluded, and high EPO levels