Erythropoietin-Resistant Anemia Secondary to Zinc-Induced Hypocupremia in a Hemodialysis Patient

Excessive intake of zinc is a known but often forgotten cause of copper deficiency, and its consequences in the context of end-stage renal disease (ESRD) are not widely discussed. Zinc-induced copper deficiency (ZICD) can result in erythropoietin (EPO)-resistant anemia and may not be considered as a possible etiology when conducting the work-up. We present a case wherein an ESRD patient had been receiving excess zinc for several months and subsequently experienced EPO-resistant anemia. Our patient's GI work-up was negative, and increased doses of iron and EPO-stimulating agent were ineffective. She underwent a bone marrow biopsy and more serological testing. She was ultimately diagnosed with ZICD, and cessation of her zinc supplement and initiation of copper replacement proved effective in restoring EPO responsiveness. Awareness of ZICD as a possible factor in EPO-resistant anemia could lead to an expedited diagnosis and avoid an unnecessary and extensive work-up.