Cyclosporine treatment for patients with CRF who developed pure red blood cell aplasia following EPO therapy

Pure red cell aplasia induced by erythropoietin

Introduction: Recombined human erythropoietin has been present in clinical practice for more than 20 years, in these therapeutic indications: anemia in kidney insufficiency, anemia during chemotherapy of tumors, prevention of anemias that appear in premature born babies, it is used for increasing autologous blood cell levels before blood transfusion, AIDS joined anemia (intensified by zidovudine), anemia joined with chronic inflammatory conditions such as rheumatoid arthritis(still in research phase). During the course of Erythropoietin treatment side effects have been noticed, that include multiple organ systems, and have different levels of frequency. Major number of studies shows connection between erythropoietin treatment and bone marrow aplasia, but small number of them states clearly defined side-effect that explains this phenomenon. Objective: Goal of this paper is to analyze available case studies of bone marrow aplasia during erythropoietin application, access their quality and causality of every study. Method: Research of literature used for the preparation of this systematic review has been conducted during the period of November-December 2017. In search for literature medical base PubMed has been used. Inclusion criteria were: available full article, publications in English language, publications conducted on humans, and case report studies. Eight studies passed selection. Results: results were presented by 5 charts: documentation size, credibility, number of case study reports of side-effects in the paper that was graded, Naranjo causality score, data extraction chart. Mean grade value of the studies quality was 7,0, while mean Naranjo score was 6,6.

Anti-erythropoietin antibodies followed by endogenous erythropoietin production in a dialysis patient

We present a case of a young girl with end-stage renal disease secondary to anti-glomerular basement membrane disease who was receiving maintenance peritoneal dialysis and developed pure red cell aplasia secondary to anti-erythropoietin (EPO) antibodies. This occurred 13 months after the initiation of EPO alfa therapy for anemia. Initially, the patient required intermittent red blood cell transfusions. After immunosuppressive therapy had been initiated with corticosteroids and cyclosporine, the EPO antibody levels decreased precipitously, associated with an increased level of endogenous EPO production. For the following 6 months, the patient maintained adequate (>10 g/dL) hemoglobin levels and did not require red cell transfusions.

Circulating antibodies to endogenous erythropoietin and risk for HIV-1-related anemia

OBJECTIVES

In a previous retrospective study we have shown that circulating antibodies to endogenous erythropoietin (anti-EPO) are associated with HIV-1-related anemia. The present longitudinal cohort study was conducted to examine the effect of anti-EPO on the risk of developing anemia over time.

METHODS

The study population consisted of 113 HIV-1 seropositive patients, who were screened for the presence of anti-EPO, with a mean+/-SD follow up of 105+/-40 months, for a total of 2190 visits. Anti-EPO were detected with an ELISA assay.

RESULTS

Anti-EPO were detected in 41% (46/113) at enrollment and 29% (320/1094) for all visits, and were associated with higher EPO levels for all visits (45.7+/-60.4 vs. 31.8+/-31.7 IU/ml, p<0.001). After adjusting for other significant confounders, anti-EPO has been associated with increased risk of anemia both at enrollment (odds ratio [OR], 5.07; 95% confidence interval [CI], 1.25-20.49) as well as for all visits ([OR], 2.15; 95% [CI]: 1.29-3.56). During follow up, a decline in prevalence of both anti-EPO and anemia was observed as the percentage of patients receiving HAART was increasing.

CONCLUSIONS

Anti-EPO are an independent risk factor for anemia in HIV-1-infected patients. HAART seems to reduce both anti-EPO and anemia prevalence.

Fellow’ Forum Fellows’ Forum in Dialysis: Response to Cyclosporine A in a Patient with Pure Red Cell Aplasia Due to Antierythropoietin-α Antibodies

Reported cases of pure red cell aplasia (PRCA) from the administration of erythropoietin (EPO)-alpha molecule in the United States are rare, and the optimal treatment is still unknown. We present a patient with end-stage renal disease (ESRD) who became hyporesponsive and later unresponsive to EPO-alpha treatment a few months after initiation of hemodialysis. A comprehensive anemia examination was negative while the patient became transfusion dependent. The diagnosis of EPO-alpha-induced PRCA was confirmed by bone marrow biopsy, by undetectable serum EPO levels following the administration of a large dose of EPO-alpha, and by documenting the presence of EPO-neutralizing antibodies. Administration of cyclosporine A in addition to prednisone enabled the patient to become transfusion and EPO independent. This case further documents the possible occurrence of PRCA with EPO-alpha administration in the United States and reaffirms the potential beneficial effect of cyclosporine A.

Erythropoietin-induced, antibody-mediated pure red cell aplasia

Pure red cell aplasia (PRCA) is a rare haematological condition that is characterized by severe aregenerative anaemia due to an almost complete cessation of red blood cell production. While antibody-mediated PRCA was extremely rare before 1998, the incidence of this disorder increased sharply after 1998 in patients receiving subcutaneous epoetin alfa produced by Ortho-Biotech and marketed outside the USA. The diagnosis of antibody-mediated PRCA relies mostly on the results of bone marrow biopsy or aspirate, which shows an absence of erythroid precursors and/or red cell maturation arrest while counts of white cell and platelet precursors are normal, and on the identification of circulating anti-erythropoietin antibodies. Retrospective analysis of PRCA cases has shown that immunosuppressive therapy can induce a disappearance of anti-erythropoietin antibodies in most patients. Eur J Clin Invest 2005; 35 (Suppl. 3): 95-99.

Rapid resolution of EPO-induced pure red cell aplasia after a course of immunoadsorption therapy using protein A columns

Pure red cell aplasia (PRCA) is a rare, but important, complication of erythropoietin (EPO) replacement therapy in patients with renal disease. There is no consensus about the best way to treat this condition; however, recent reports indicated that immunosuppressive therapy is beneficial. We report a patient with EPO-induced PRCA treated with a regimen initially designed for antifactor VIII antibodies in patients with hemophilia. This regimen consists of immunoadsorption therapy using protein A columns, followed by oral prednisolone and single bolus infusions of intravenous immunoglobulin G and cyclophosphamide. Shortly after the course, a swift and rapid increase in reticulocyte count was evident; the patient became transfusion independent and has remained so during 2 years of follow-up. By means of this report, we wish to encourage others to consider this option when first-line treatments fail.

A cross-sectional immunosurveillance study of anti-EPO antibody levels in CRF patients receiving epoetin alfa in 5 Ontario Renal Centers

BACKGROUND

Epoetin alfa (Eprex*; Johnson & Johnson, Manati, PR) has been used successfully to correct the anemia of chronic renal failure for more than 12 years. Anti-erythropoietin (anti-EPO) antibodies have been reported in a small number of patients, resulting in a blood disorder, pure red cell aplasia (PRCA). To evaluate the utility of a large-scale anti-EPO antibody screening program in patients with chronic kidney disease (CKD) administered epoetin alfa, a study involving 5 large renal centers in southern Ontario, Canada, was conducted.

METHODS

More than 1,500 hemodialysis, peritoneal dialysis, and predialysis patients were screened for the prevalence of anti-EPO antibodies by means of a radioimmunoprecipitation (RIP) assay. Serum samples were drawn and shipped to PPD Development (Richmond, VA) for the immunoprecipitation assay. Serum EPO levels also were measured. All samples that tested positive or borderline for antibodies were sent to MDS Pharma Services (Montreal, Canada) for the neutralization assay.

RESULTS

Of 1,531 samples tested, 1 patient tested low-positive and 3 borderline results were detected by means of RIP. PRCA previously was diagnosed in the patient with the low-positive antibody level; the patient was treated with cyclosporine and currently is being administered epoetin alfa with good response. The 3 patients with borderline antibody results manifested no clinical signs of PRCA. Neutralization assays performed on all 4 serum samples were negative for anti-EPO antibodies.

CONCLUSION

Results from this surveillance study show that the prevalence of antibody to EPO in patients with CKD administered epoetin alfa in 5 Canadian renal centers is low, and the value of a large-scale antibody screening program for PRCA cannot be justified.

Prolonged course of pure red cell aplasia after erythropoietin therapy

Pure red cell aplasia (PRCA) caused by neutralising anti-erythropoietin antibodies is a very rare disease. Since 1998, an increased incidence of PRCA in patients with kidney failure following treatment with recombinant human erythropoietin (rhEpo) has been reported, mostly in Europe. In most cases, PRCA was cured by immunosuppressive therapy, immunoglobulins, plasmapheresis or renal transplantation. We report an exceptionally prolonged course of PRCA over 68 months despite renal transplantation and different immunosuppressive regimens.

Treatment of erythropoietin-induced pure red cell aplasia: a retrospective study

BACKGROUND

Recombinant human erythropoietin is the standard treatment for anaemia related to chronic kidney disease, and its widespread use has been favoured by a very high therapeutic index. However, since 1998, more than 200 patients worldwide with chronic kidney disease treated in this way have developed neutralising antibodies to erythropoietin, causing pure red cell aplasia. We aimed to collate clinical and pathological features in patients unequivocally shown to have erythropoietin-induced pure red cell aplasia.

METHODS

We retrospectively obtained data from the files of 47 patients with pure red cell aplasia. We assessed treatment and outcome of patients and defined recovery from pure red cell aplasia as an increase in reticulocyte counts to more than 20 000 per microL in patients who were no longer transfusion-dependent.

FINDINGS

When patients developed pure red cell aplasia, all were receiving erythropoietin subcutaneously, and the product most typically prescribed was epoetin alfa (Eprex, Ortho Biotech). The median delay between start of erythropoietin treatment and occurrence of pure red cell aplasia was 11 months (IQR 7.5-14). Nine patients received no immunosuppressive treatment, and none of these recovered. Of 37 patients who received immunosuppressive therapy, 29 (78%) recovered. All six patients who received a kidney transplant recovered within 1 month, and recovery rates were between 56% and 88% in patients treated with corticosteroids, corticosteroids plus cyclophosphamide, or ciclosporin. No relapse of pure red cell aplasia happened after stopping immunosuppressive treatment, but no patient was rechallenged with erythropoietin.

INTERPRETATION

Immunosuppressive treatment accelerates recovery from erythropoietin-induced pure red cell aplasia.

Recovery from pure red cell aplasia caused by anti-erythropoietin antibodies after kidney transplantation

The use of recombinant human erythropoietin (rHuEPO) is a major advance in the treatment of patients with anemia caused by chronic renal failure (CRF). The development of antierythropoietin (anti-EPO) antibodies following treatment with rHuEPO has been observed in an increasing number of patients. This causes pure red cell aplasia (PRCA) and requires the definitive withdrawal of rHuEPO. Many patients require immunosuppressive therapy before anti-EPO antibodies disappear completely. We report a case of PRCA owing to anti-EPO in a 20-year-old hemodialyzed man who was receiving immunosuppressive therapy for a liver transplantation carried out in childhood. He required repeated red cell transfusions until a kidney transplantation was performed. He received an induction therapy with antithymocyte globulins and a maintenance regimen consisting of steroids, tacrolimus and mycophenolate mofetil. This new immunosuppressive treatment led to the complete disappearance of anti-EPO antibodies within a few weeks after the kidney transplantation. Erythropoiesis and endogenous erythropoietin synthesis were restored following transplantation, without leading to an increase in the titer of anti-EPO antibodies.