Anemia in an HCV and ESRD patient

Case: 54 years old male with a past medical history of end-stage renal disease (ESRD) and on regular hemodialysis is admitted to ICU with severe anemia. Patient is recently started on anti-Hepatitis C drugs. Which drug is the most probable culprit?

Answer: Ribavarin

Once a patient is started on Ribavirin, patient should be watched for hemolysis. The following patients' population are at high risk:

1. pre-existing anemia - even with previous mild anemia i.e., below 12 g/dL (males) or <11 g/dL (females)

2. renal insufficiency - even mild insufficiency, i.e., GFR below 60 mL/min per 1.73 m2

3. coronary artery disease

4. history of hemoglobinopathies

Also, it should be avoided in pregnant females (highly teratogenic).

                                                                             

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References:

1. Soota K, Maliakkal B. Ribavirin induced hemolysis: a novel mechanism of action against chronic hepatitis C virus infection. World J Gastroenterol. 2014 Nov 21;20(43):16184-90. doi: 10.3748/wjg.v20.i43.16184. PMID: 25473172; PMCID: PMC4239506.

                                                                             

2. Reichard O, Schvarcz R, Weiland O. Therapy of hepatitis C: alpha interferon and ribavirin. Hepatology 1997; 26:108S.