Acute Tubular Necrosis (ATN) after Hemopure in a Patient with Sickle Cell Disease (SCD)

Introduction: Hemopure (HBOC-201) is a bovine hemoglobin-based oxygen carrier (HBOC), classified as a semi-synthetic, cell-free, purified hemoglobin product. It effectively binds and delivers oxygen to tissues, mimicking the function of red blood cells. This is the first case report, to our knowledge, which details the clinical trajectory of a patient who developed ATN after hemopure administration. Case Description: A 57-year-old female Jehovah's Witness with SCD and vaso-occlusive crisis was intubated for mixed respiratory failure. She had influenza pneumonia and pulmonary edema attributed to high output failure from severe anemia. Her blood pressure (BP) was normal. Her laboratory results showed a hemoglobin (Hgb) of 6.0 g/dL and a creatinine (Cr) of 1.1 mg/dL. Her ferritin was 1365 ng/mL. She was given Epogen 20,000 IU daily and was diuresed with robust urinary response (3L/24hr). Her Cr remained 1.0-1.3 mg/dL over the following days; however, her Hgb decreased 5.3 to 4.9 g/dL, and she was given 2 units (32.5 g/unit) of IV Hemopure. The day after infusion, her Cr increased to 1.8 mg/dL and her systolic BP rose to 200 mmHg. A urine sediment showed muddy brown casts suggestive of ATN. A renal ultrasound with doppler showed no renal papillary necrosis or obstruction. She became progressively volume overloaded and started urgent peritoneal dialysis. Further doses of Hemopure were held, her volume status improved, and she was extubated. One month later, she demonstrated renal recovery to baseline kidney function. Discussion: Hemopure has been approved for use by the FDA’s Expanded Access Program since 2013 for patients with life-threatening anemia who are unable to receive blood transfusions. HBOCs offer several unique advantages such as reduced risk of alloimmunization and infection. They have been hypothesized to reverse the sickling process in SCD. As a bloodless medicine, they can be utilized in patients who decline blood transfusions for religious reasons like Jehovahs’ Witness. Hemopure trials in surgical patients resulted in increased mean arterial pressure, serum urea (N2), bicarbonate, and base extract. Renal side effects include hypertension attributed to heme scavenging of endothelial nitric oxide, and nephrotoxicity possibly from renal oxidative stress and vasoconstriction. This case seeks to contribute to the growing body of literature on the safety and risks associated with HBOCs.