Erythropoietin resistance due to dialysate chloramine: the two-way traffic of solutes in haemodialysis

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Abstract
Renal anaemia is primarily a consequence of erythropoietin deficiency and is amenable to treatment with exogenous erythropoietin. Erythropoietin is expensive and can consume a large proportion of the budget for end-stage renal replacement therapy so that any cause of erythropoietin resistance has important resource implications. The usual cause of erythropoietin resistance is inadequate available iron for erythropoiesis in the bone marrow although the definitive list is long [1]. We developed a clinical management system in an attempt to improve the cost-benefit ratio for erythropoietin and intravenous iron therapy in our haemodialysis population. We encountered a potent and insidious cause of anaemia in a subset of our haemodialysis population from a recognized cause not usually included in such a list. Investigations were prompted by continuous audit of the management of renal anaemia, which indicated that patients in one of our satellite units suffered declining haemoglobin concentrations despite adequate iron therapy and steadily increasing doses of erythropoietin.