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Lobbes H, Lega JC, Le Guenno G, Ruivard M, Mainbourg S. Treatment strategy for acquired pure red cell aplasia: a systematic review and meta-analysis. Blood Adv 2023; 7:6451-6465. [PMID: 37624775 PMCID: PMC10632686 DOI: 10.1182/bloodadvances.2023010587] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/22/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
The treatment of autoimmune acquired pure red cell aplasia (aPRCA) is challenging. Guidelines are based on expert recommendations in the absence of controlled trials. We assessed the efficacy of the main treatment strategy through a systematic review and meta-analysis using MEDLINE, EMBASE, and the Cochrane Library up to September 2022. The overall response rate (ORR) was pooled using random-effects models. In total, 24 observational studies (19 retrospective, median follow-up of 48 months) encompassing 753 patients (49% male) were included. Primary aPRCA represented 57% of the cases. The risk of bias was moderate to high using the ROBINS-I tool. Substantial heterogeneity (I2 > 50%) was retrieved. Corticosteroids as monotherapy as first-line treatment (186 patients, 13 studies) provided an ORR of 47% (95% confidence interval [CI], 34-60). Cyclosporine A was the most frequently used immunosuppressant agent (384 patients, 18 studies), providing an ORR of 74% (95% CI, 66-82) with a similar ORR in first- (73%) and second-line (76%) treatment and when cyclosporin was used as monotherapy (83%) or with corticosteroids (77%). A total of 112 patients (10 studies) received cyclophosphamide, with an ORR of 49% (95% CI, 35-64), which was higher when cyclophosphamide was combined with corticosteroids (48%) and used in second-line treatment (58%) than in monotherapy (31%), and in first-line treatment (44%). Sirolimus use was reported only after cyclosporine A failure and provided an ORR of 87% (95% CI, 68-100; 64 patients, 3 studies). Substantial uncertainty remains regarding the best treatment strategy in the absence of high-quality evidence. This study was registered on the PROPERO database as #CRD42022360452.
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Affiliation(s)
- Hervé Lobbes
- Service de Médecine Interne, Hôpital Estaing, Centre Hospitalier Universitaire de Clermont-Ferrand, Centre de Compétence des cytopénies autoimmunes de l’adulte, Clermont-Ferrand, France
- Institut Pascal, Centre Hospitalier Universitaire de Clermont-Ferrand, Université Clermont Auvergne, Centre National de la Recherche Scientifique, Clermont-Ferrand, France
| | - Jean-Christophe Lega
- Lyon Immunopathology Federation, Hospices Civils de Lyon, Lyon, France
- Service de Rhumatologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
- Equipe Evaluation et Modélisation des Effets Thérapeutiques, Unité Mixte de Recherche 5558, Laboratoire de Biométrie et Biologie évolutive, Centre National de la Recherche Scientifique, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Guillaume Le Guenno
- Service de Médecine Interne, Hôpital Estaing, Centre Hospitalier Universitaire de Clermont-Ferrand, Centre de Compétence des cytopénies autoimmunes de l’adulte, Clermont-Ferrand, France
| | - Marc Ruivard
- Service de Médecine Interne, Hôpital Estaing, Centre Hospitalier Universitaire de Clermont-Ferrand, Centre de Compétence des cytopénies autoimmunes de l’adulte, Clermont-Ferrand, France
- Institut Pascal, Centre Hospitalier Universitaire de Clermont-Ferrand, Université Clermont Auvergne, Centre National de la Recherche Scientifique, Clermont-Ferrand, France
| | - Sabine Mainbourg
- Lyon Immunopathology Federation, Hospices Civils de Lyon, Lyon, France
- Equipe Evaluation et Modélisation des Effets Thérapeutiques, Unité Mixte de Recherche 5558, Laboratoire de Biométrie et Biologie évolutive, Centre National de la Recherche Scientifique, Université Claude Bernard Lyon 1, Villeurbanne, France
- Département de Médecine Interne, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
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2
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Means RT. Pure red cell aplasia: The second hundred years. Am J Med Sci 2023; 366:160-166. [PMID: 37327996 DOI: 10.1016/j.amjms.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/05/2023] [Accepted: 06/13/2023] [Indexed: 06/18/2023]
Abstract
Pure red cell aplasia (PRCA) is a rare hematologic syndrome, characterized by an isolated normocytic anemia with severe reticulocytopenia, and defined by absence or near absence of erythroid precursors in the bone marrow. First described in 1922, PRCA may be a primary autoimmune or clonal myeloid or lymphoid disorder, but may also be secondary to other disorders of immune dysregulation/autoimmunity, to infections, to neoplasms, or to drugs. Insights from the study of PRCA have helped illuminate the understanding of the regulation of erythropoiesis. This review summarizes the classification, diagnostic, and therapeutic approach to PRCA as it begins its second century, with a particular focus on opportunities and challenges provided by new developments in the role of T-cells and T-cell regulatory mutations; the role of clonal hematopoiesis; and new developments in therapy for refractory PRCA and PRCA associated with ABO incompatible stem cell transplantation.
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Affiliation(s)
- Robert T Means
- Departments of Internal Medicine, Medical Education, and Pathology, James H. Quillen College of Medicine, Johnson City, TN, USA.
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3
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Gordon MJ, Ferrajoli A. Unusual complications in the management of chronic lymphocytic leukemia. Am J Hematol 2022; 97 Suppl 2:S26-S34. [PMID: 35491515 DOI: 10.1002/ajh.26585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 02/04/2023]
Abstract
Chronic lymphocytic leukemia (CLL) is a common, indolent disease that typically presents with a proliferation of mature, immunologically dysfunctional CD5+ B-cells which preferentially occupy the bone marrow, peripheral blood and lymphoid organs. Immune dysfunction leads to an increase in autoimmune diseases which occur in approximately 10% of patients with CLL. Autoimmune cytopenias are the most common, but other organs may be affected as well. The treatment of these conditions typically depends on the extent of CLL and severity of symptoms, but generally consists of CLL-directed therapies, immunosuppression or both. CLL may also infiltrate extranodal sites in the body. Symptomatic extranodal CLL or extranodal disease which threatens normal organ function is an indication for initiation of CLL-directed therapy. The following review summarizes autoimmune and extranodal complications that can occur in patients with CLL and our suggested approach to their treatment.
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Affiliation(s)
- Max J Gordon
- MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
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4
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Nagib AM, Gheith OA, Zahab MA, Balaha MA, Elserwey NA, Sobhy I, Nair P, Al-Otaibi T. Pure Red Cell Aplasia in a Renal Transplant Recipient: Case Report and Review of the Literature. EXP CLIN TRANSPLANT 2022; 20:136-139. [PMID: 35384824 DOI: 10.6002/ect.mesot2021.p66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Severe anemia requiring multiple blood transfusions in the posttransplant period can trigger rejection. The evaluation of anemia among transplant recipients is a challenging task. Awareness should be continued for tacrolimus to manage pure red cell aplasia, but further evidence is needed to prove whether tacrolimus is a real cause of posttransplant anemia. Our case patient, a 66-year-old male patient with end-stage renal disease due to diabetic nephropathy, underwent a preemptive living donor renal transplant in September 2018. He had received a coronary artery bypass graft with transcatheter aortic valve implantation 3 years before renal transplant. Initially, he was maintained on prednisolone, mycophenolate mofetil, and tacrolimus after basiliximab induction. One month later, he presented with low cardiac output symptoms. His complete blood count showed normocytic normochromic anemia with reticulocytopenia (his hemoglobin level dropped from 112 to 69 g/L), which necessitated regular blood transfusions. His iron profile, serum folate, and vitamin B12 were within normal limits, and he had negative hemolytic and autoimmune screening tests. A bone marrow biopsy revealed acquired pure red cell aplasia, which was most likely drug induced as viral profiles were negative for parvovirus B19, cytomegalovirus, and Epstein-Barr virus. The patient was managed by discontinuing mycophenolate mofetil, and the steroid dose was increased up to 20 mg/day but without improvement. With tacrolimus then considered, 3 weeks after presentation, we replaced tacrolimus with cyclosporine. Complete blood count follow-up showed improvement without any need for further blood transfusions. After 1 month of cyclosporine maintenance, mycophenolate mofetil was resumed with a steady increase of hemoglobin up to 150 g/L and serum creatinine of 122 μmol/L. Pure red cell aplasia is a rare disorder among renal transplant recipients, which could be induced by maintenance tacrolimus therapy.
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Affiliation(s)
- Ayman M Nagib
- From the Nephrology Department, Hamed Al-Essa Organ Transplant Center, Sabah Area, Kuwait.,From the Nephrology Department of Dialysis and Transplantation, Urology Nephrology Center, Mansoura University, Mansoura, Egypt
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5
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Huang Y, Jiang X, Han B. Effective treatment of refractory acquired pure red blood cell aplasia with eltrombopag and sirolimus: a case report. Ther Adv Hematol 2020; 11:2040620720940144. [PMID: 32733663 PMCID: PMC7372523 DOI: 10.1177/2040620720940144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/11/2020] [Indexed: 12/17/2022] Open
Abstract
Acquired pure red cell aplasia (aPRCA) is a kind of anemia characterized
by severe reticulocytopenia and reduced bone marrow erythroblastic
cells. For patients who are refractory to the first-line therapy
(cyclosporin A with/without glucocorticoids), second-line therapy is
considered less effective. We report on a patient with primary aPRCA
who was refractory to cyclosporin A, glucocorticoids, and several
second-line regimens. The patient was treated with sirolimus for
10 months with no improvement in hemoglobin but complete response was
achieved after adding eltrombopag at a dosage of 25 mg/day.
Eltrombopag was well tolerated with no evidence of clonal evolution at
the end of follow up. This case provided a new attempt at treating
patients with refractory/relapse aPRCA with eltrombopag, probably in
combination with sirolimus.
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Affiliation(s)
- Yuzhou Huang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xianyong Jiang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuaifuyuan No. 1, Dongcheng District, Beijing 100730, China
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Amanatidou AI, Nastou KC, Tsitsilonis OE, Iconomidou VA. Visualization and analysis of the interaction network of proteins associated with blood-cell targeting autoimmune diseases. Biochim Biophys Acta Mol Basis Dis 2020; 1866:165714. [DOI: 10.1016/j.bbadis.2020.165714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 01/21/2020] [Accepted: 01/31/2020] [Indexed: 12/17/2022]
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[How I diagnose and treat pure red cell aplasia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:5-9. [PMID: 32023747 PMCID: PMC7357908 DOI: 10.3760/cma.j.issn.0253-2727.2020.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Immunosuppressive therapy for elderly-acquired pure red cell aplasia: cyclosporine A may be more effective. Ann Hematol 2020; 99:443-449. [PMID: 31970447 DOI: 10.1007/s00277-020-03926-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 01/14/2020] [Indexed: 10/25/2022]
Abstract
This current study retrospectively analyzed the clinical characteristics of 69 adult patients with acquired pure red cell aplasia (PRCA) including 40 elderly and 29 non-elderly patients from September 2009 to June 2019. The remission induction therapy regimens included cyclosporine A (CsA), corticosteroids (CS), or other immunosuppressive agents. The overall response rate was 55% (22/40) in the elderly group compared with 75.9% (22/29) in non-elderly patients (P = 0.075). In elderly patients, the best remission was achieved in the group treated with CsA than those treated with CS or other immunosuppressive agents (83.3% vs 26.7% vs 42.9%%, P = 0.004). However, outcomes of remission were similar among different treatment groups (P = 0.458) in non-elderly patients. CS induced a higher response rate in the non-elderly than that in the elderly (88.9% vs 26.7%, P = 0.009). By univariate and multivariate analysis, the clinical efficacy of elderly patients with acquired PRCA was closely associated with an induction regimen of CsA (P = 0.009; P = 0.017). In conclusion, CsA might produce higher response rate than CS and other drugs in elderly patients with acquired PRCA.
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9
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Pure Red Cell Aplasia with Del(20q) Sensitive for Immunosuppressive Treatment. Case Rep Hematol 2020; 2020:1262038. [PMID: 32082654 PMCID: PMC6995481 DOI: 10.1155/2020/1262038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 12/13/2019] [Accepted: 12/28/2019] [Indexed: 11/17/2022] Open
Abstract
Pure red cell aplasia (PRCA) is a rare syndrome that only affects the erythroid lineage. It is defined by a normocytic, normochromic anemia with a marked reticulocytopenia and severe reduction or absence of erythroid precursors in the bone marrow. Treatment of primary, idiopathic PRCA is immunosuppressive therapy. Although it is rare, isolated cytogenetic abnormalities can be seen in PRCA, and abnormal karyotype is associated with poor response to immunosuppressive therapy and poor prognosis. We describe a 77-year-old male with primary, idiopathic PRCA and a deletion of chromosome 20q, del(20q), in the bone marrow cells. He was successfully treated with immunosuppressive therapy and became transfusion-independent. The same cytogenetic abnormality has also been described in a few other reports; taken together, these observations suggest that del(20q) may represent a recurrent cytogenetic abnormality in PRCA. Our case report clearly illustrates that even patients with primary PRCA and an abnormal karyotype can respond to immunosuppression and become transfusion-independent.
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11
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Abstract
Pure red cell aplasia (PRCA) is a syndrome defined by a normocytic normochromic anemia with severe reticulocytopenia and marked reduction or absence of erythroid precursors from the bone marrow. Diamond-Blackfan anemia is a congenital form of PRCA. Acquired PRCA may be either a primary disorder or secondary to some other disorder or agent. Primary acquired PRCA is an autoimmune disorder that is frequently antibody-mediated. Myelodysplastic syndromes may also present with the morphologic appearance of PRCA. Secondary acquired PRCA may be associated with collagen vascular/autoimmune disorders such as systemic lupus erythematosus; lymphoproliferative disorders such as chronic lymphocytic leukemia or large granular lymphocyte leukemia; infections, particularly B19 parvovirus; thymoma and other solid tumors; or a variety of other disorders, drugs, or toxic agents. The therapeutic approach to PRCA typically involves immunosuppression, but specific pathogenic subtypes are associated with specific therapeutic approaches. Cyclosporine A, with or without concurrent corticosteroids, appears to be the single most effective immunosuppressive agent.
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12
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Abstract
Pure red cell aplasia (PRCA) is a syndrome defined by a normocytic normochromic anemia with severe reticulocytopenia and marked reduction or absence of erythroid precursors from the bone marrow. Diamond-Blackfan anemia is a congenital form of PRCA. Acquired PRCA may be either a primary disorder or secondary to some other disorder or agent. Primary acquired PRCA is an autoimmune disorder that is frequently antibody-mediated. Myelodysplastic syndromes may also present with the morphologic appearance of PRCA. Secondary acquired PRCA may be associated with collagen vascular/autoimmune disorders such as systemic lupus erythematosus; lymphoproliferative disorders such as chronic lymphocytic leukemia or large granular lymphocyte leukemia; infections, particularly B19 parvovirus; thymoma and other solid tumors; or a variety of other disorders, drugs, or toxic agents. The therapeutic approach to PRCA typically involves immunosuppression, but specific pathogenic subtypes are associated with specific therapeutic approaches. Cyclosporine A, with or without concurrent corticosteroids, appears to be the single most effective immunosuppressive agent.
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MESH Headings
- Adrenal Cortex Hormones/therapeutic use
- Anemia, Diamond-Blackfan/drug therapy
- Anemia, Diamond-Blackfan/immunology
- Anemia, Diamond-Blackfan/pathology
- Autoimmune Diseases/drug therapy
- Autoimmune Diseases/immunology
- Autoimmune Diseases/pathology
- Cyclosporine/therapeutic use
- Humans
- Immunosuppressive Agents/therapeutic use
- Leukemia, Large Granular Lymphocytic/drug therapy
- Leukemia, Large Granular Lymphocytic/immunology
- Leukemia, Large Granular Lymphocytic/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Myelodysplastic Syndromes/drug therapy
- Myelodysplastic Syndromes/etiology
- Myelodysplastic Syndromes/immunology
- Myelodysplastic Syndromes/pathology
- Parvoviridae Infections/drug therapy
- Parvoviridae Infections/immunology
- Parvoviridae Infections/pathology
- Parvovirus B19, Human/immunology
- Thymoma/drug therapy
- Thymoma/immunology
- Thymoma/pathology
- Vasculitis/drug therapy
- Vasculitis/immunology
- Vasculitis/pathology
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Affiliation(s)
- Robert T Means
- Office of the Dean, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN
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13
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Lei DM, Piao SG, Jin YS, Jin H, Cui ZH, Jin HF, Jin JZ, Zheng HL, Li JJ, Jiang YJ, Yang CW, Li C. Expression of erythropoietin and its receptor in kidneys from normal and cyclosporine-treated rats. Transplant Proc 2014; 46:521-8. [PMID: 24656003 DOI: 10.1016/j.transproceed.2013.12.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 12/07/2013] [Accepted: 12/16/2013] [Indexed: 01/08/2023]
Abstract
Long-term treatment with cyclosporine A (CsA) is associated with various types of complications; however, CsA-induced anemia has not been reported. The present study examined the impact of CsA on hematopoietic parameters and intrarenal expression of erythropoietin (EPO) and the EPO receptor (EPOR) in a rat model of chronic CsA nephrotoxicity. Sprague-Dawley rats were fed a low-salt diet (0.05% sodium) and were treated daily for 4 weeks with vehicle (olive oil 1 mL/kg subcutaneously) or CsA (15 mg/kg subcutaneously). The expression of EPO and EPOR was evaluated by immunohistochemistry and immunoblotting, and hematopoietic parameters were assessed by measuring blood hemoglobin and hematocrit levels, and these variables were compared between treatment groups. Renal function, oxidative stress, histopathology (tubulointerstitial fibrosis), apoptotic cell death, and expression of transforming growth factor β-inducible gene-h3 (βig-h3) were also compared between treatment groups. In kidneys from vehicle-treated rats, endogenous EPO and EPOR protein were expressed constitutively in the outer stripe of the outer medulla and the cortex. EPO protein expression decreased significantly in kidneys from CsA-treated rats. By contrast, EPOR expression was higher in kidneys from CsA-treated rats than in vehicle-treated rats. These changes were accompanied by decreases in serum hemoglobin and hematocrit levels and correlated with the number of cells positive for terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (r = -0.769, P = .003) and βig-h3 protein expression (r = -0.910, P < .001). Long-term treatment with CsA suppresses renal endogenous EPO expression, resulting in anemia. Increases in apoptotic cell death and βig-h3 expression are closely associated with inhibition of EPO expression in chronic CsA nephrotoxicity.
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Affiliation(s)
- D M Lei
- Nephrology and Dialysis Unit, Department of Internal Medicine, YanBian University Hospital, Jilin, China
| | - S G Piao
- Nephrology and Dialysis Unit, Department of Internal Medicine, YanBian University Hospital, Jilin, China; Transplant Research Center, Convergent Research Consortium for Immunologic Disease, Seoul St. Mary's Hospital, Catholic University of Korea, Seoul, Korea
| | - Y S Jin
- Nephrology and Dialysis Unit, Department of Internal Medicine, YanBian University Hospital, Jilin, China
| | - H Jin
- Nephrology and Dialysis Unit, Department of Internal Medicine, YanBian University Hospital, Jilin, China
| | - Z H Cui
- Nephrology and Dialysis Unit, Department of Internal Medicine, YanBian University Hospital, Jilin, China
| | - H F Jin
- Nephrology and Dialysis Unit, Department of Internal Medicine, YanBian University Hospital, Jilin, China
| | - J Z Jin
- Nephrology and Dialysis Unit, Department of Internal Medicine, YanBian University Hospital, Jilin, China
| | - H L Zheng
- Nephrology and Dialysis Unit, Department of Internal Medicine, YanBian University Hospital, Jilin, China
| | - J J Li
- Nephrology and Dialysis Unit, Department of Internal Medicine, YanBian University Hospital, Jilin, China
| | - Y J Jiang
- Nephrology and Dialysis Unit, Department of Internal Medicine, YanBian University Hospital, Jilin, China
| | - C W Yang
- Transplant Research Center, Convergent Research Consortium for Immunologic Disease, Seoul St. Mary's Hospital, Catholic University of Korea, Seoul, Korea
| | - C Li
- Nephrology and Dialysis Unit, Department of Internal Medicine, YanBian University Hospital, Jilin, China.
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Anti-erythropoietin antibodies followed by endogenous erythropoietin production in a dialysis patient. Pediatr Nephrol 2010; 25:971-6. [PMID: 20091055 DOI: 10.1007/s00467-009-1406-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Revised: 11/24/2009] [Accepted: 11/25/2009] [Indexed: 10/19/2022]
Abstract
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.
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Sawada K, Fujishima N, Hirokawa M. Acquired pure red cell aplasia: updated review of treatment. Br J Haematol 2008; 142:505-14. [PMID: 18510682 PMCID: PMC2592349 DOI: 10.1111/j.1365-2141.2008.07216.x] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pure red cell aplasia (PRCA) is a syndrome characterized by a severe normocytic anaemia, reticulocytopenia, and absence of erythroblasts from an otherwise normal bone marrow. Primary PRCA, or secondary PRCA which has not responded to treatment of the underlying disease, is treated as an immunologically-mediated disease. Although vigorous immunosuppressive treatments induce and maintain remissions in a majority of patients, they carry an increased risk of serious complications. Corticosteroids were used in the treatment of PRCA and this has been considered the treatment of first choice although relapse is not uncommon. Cyclosporine A (CsA) has become established as one of the leading drugs for treatment of PRCA. However, common concerns have been the number of patients treated with CsA who achieve sustained remissions and the number that relapse. This article reviews the current status of CsA therapy and compares it to other treatments for diverse PRCAs.
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Affiliation(s)
- Kenichi Sawada
- Department of Internal Medicine III, Division of Haematology, Akita University Graduate School of Medicine, Akita, Japan.
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Abstract
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.
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Vales-Albertos LJ, García-Cárdenas M, Chávez-Becerra S, Gómez-Navarro B, Monteón-Ramos F, Cueto-Manzano AM. Pure red cell aplasia associated with parvovirus B19 infection in renal transplantation: the first case report in Mexico. Transplantation 2005; 79:739. [PMID: 15785387 DOI: 10.1097/01.tp.0000149339.25047.f4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Summers SA, Matijevic A, Almond MK. Successful re-introduction of recombinant human erythropoietin following antibody induced pure red cell aplasia. Nephrol Dial Transplant 2004; 19:2137-9. [PMID: 15252175 DOI: 10.1093/ndt/gfh319] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Shaun A Summers
- Renal Medicine, Southend General Hospital, Westcliff-on-Sea, Essex, UK.
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19
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Al-Uzri A, Yorgin PD, Kling PJ. Anemia in children after transplantation: etiology and the effect of immunosuppressive therapy on erythropoiesis. Pediatr Transplant 2003; 7:253-64. [PMID: 12890002 DOI: 10.1034/j.1399-3046.2003.00042.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Anemia in children after renal transplantation is more common than previously appreciated. Multiple factors appear to play roles in the development of post-transplant anemia, the most common of which is absolute and/or functional iron deficiency anemia. Most experts recommend that iron limited anemias in transplant patients should be diagnosed using the same criteria as for chronic renal failure patients. Serum erythropoietin (EPO) levels are expected to normalize after a successful renal transplantation with a normal kidney function, yet both EPO deficiency and resistance have been reported. While no large controlled trials comparing the effect of different immunosuppressive agents on erythropoiesis after transplantation have been performed, generalized bone marrow suppression attributable to azathioprine (AZA), mycophenolate mofetil (MMF), tacrolimus, antithymocyte preparations has been reported. Pure red cell aplasia (PRCA) occurs rarely after transplantation and is characterized by the selective suppression of erythroid cells in the bone marrow. PRCA has been reported with the use of AZA, MMF, tacrolimus, angiotensin converting enzyme inhibitors (ACEI), but not with cyclosporine (CSA) use. Post-transplant hemolytic uremic syndrome has been reported with orthoclone anti T-cell antibody (OKT3), CSA and tacrolimus therapy. Viral infections including cytomegalovirus, Epstein-Barr virus and human parvovirus B19 have been reported to cause generalized marrow suppression. Management of severe anemia associated with immunosuppressive drugs generally requires lowering the dose, drug substitution or, when possible, discontinuation of the drug. Because this topic has been incompletely studied, our recommendation as to the best immunosuppressive protocol after renal transplantation remains largely dependent on the clinical response of the individual patient.
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Affiliation(s)
- Amira Al-Uzri
- Department of Pediatrics, Section of Pediatric Nephrology, Oregon Health Sciences University, 707 SW Gaines Road, Portland, OR, USA.
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Grigg A, O'Flaherty E. Cyclosporin A for the Treatment of Pure Red Cell Aplasia Associated with Myelodysplasia. Leuk Lymphoma 2001. [DOI: 10.1080/10428190127501] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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MESH Headings
- Adult
- Anemia, Aplastic/therapy
- Anemia, Sickle Cell/physiopathology
- Anemia, Sickle Cell/therapy
- Antibodies, Anti-Idiotypic/immunology
- Antigens, Human Platelet/immunology
- Autoantibodies/immunology
- Autoimmune Diseases/immunology
- Autoimmune Diseases/therapy
- Babesiosis/therapy
- Blood Coagulation Disorders/immunology
- Blood Coagulation Disorders/therapy
- Blood Coagulation Factors/immunology
- Blood Component Removal
- Blood Group Incompatibility/therapy
- Blood Viscosity
- Bone Marrow Transplantation/immunology
- Child
- Clinical Trials as Topic
- Combined Modality Therapy
- Erythroblastosis, Fetal/therapy
- Hematologic Diseases/therapy
- Hemochromatosis/drug therapy
- Hemochromatosis/therapy
- Humans
- Infant, Newborn
- Kidney Diseases/etiology
- Kidney Diseases/therapy
- Leukocytosis/drug therapy
- Leukocytosis/radiotherapy
- Leukocytosis/therapy
- Lymphoma, T-Cell, Cutaneous/drug therapy
- Lymphoma, T-Cell, Cutaneous/therapy
- Malaria/drug therapy
- Malaria/therapy
- Multiple Myeloma/complications
- Multiple Myeloma/therapy
- Neoplasms/therapy
- Paraproteinemias/physiopathology
- Paraproteinemias/therapy
- Photopheresis
- Plasma Exchange
- Polycythemia/drug therapy
- Polycythemia/therapy
- Polycythemia Vera/drug therapy
- Polycythemia Vera/therapy
- Purpura, Thrombocytopenic/drug therapy
- Purpura, Thrombocytopenic/etiology
- Purpura, Thrombocytopenic/therapy
- Purpura, Thrombotic Thrombocytopenic/therapy
- Randomized Controlled Trials as Topic
- Red-Cell Aplasia, Pure/therapy
- Thrombocytosis/drug therapy
- Thrombocytosis/therapy
- Transfusion Reaction
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Affiliation(s)
- K M Grima
- Clinical Services, New York Blood Center, Valhalla, NY 10595, USA.
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Masuda M, Arai Y, Nishina H, Fuchinoue S, Mizoguchi H. Large granular lymphocyte leukemia with pure red cell aplasia in a renal transplant recipient. Am J Hematol 1998; 57:72-6. [PMID: 9423821 DOI: 10.1002/(sici)1096-8652(199801)57:1<72::aid-ajh13>3.0.co;2-b] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Neoplastic disorders sometimes accompany a renal transplant. Herein, we report a large granular lymphocyte (LGL) leukemia patient with pure red cell aplasia (PRCA) after renal transplantation. A 36-year-old female was presented to our department with anemia in February 1996. She had undergone hemodialysis because of pregnancy in December 1981. She received a renal transplantation from her mother in April 1986. After the transplantation, she received cyclosporin A (CyA) at 2 mg/kg/day, mizoribine at 1 mg/kg/day, and methylprednisolone at 0.1 mg/kg/day for 8 years. In July 1995, her hemoglobin level dropped to 9.3 g/dl, and anemia developed gradually. In January 1996, her hemoglobin was 5.8 g/dl, and she was given a red blood cell transfusion. Laboratory findings were as follows: RBC 1.46 x 10(12)/L; hemoglobin 5.8 g/dl; hematocrit 17.8%; leucocytes 5.2 x 10(9)/L with 62.4% neutrophils, 34.1% lymphocytes, 2.6% monocytes; platelets 50.8 x 10(10)/L; reticulocytes 0.4%. Bone marrow aspirate smears and biopsy sections revealed normal myeloid and megakaryocyte differentiation with few erythroid precursors. The lymphocytes were of medium size with granules in the cytoplasm. More than 90% of lymphocytes were of the LGL type. Surface markers of peripheral blood mononuclear cells demonstrated increases in the CD2+, CD3+, CD4-, and CD8+ populations. A monoclonal rearrangement of T-cell receptor (TCR)-beta chain gene was found by Southern blot analysis of the mononuclear cells in peripheral blood. A diagnosis of LGL leukemia with PRCA was made. During the next 4 months, she received six red blood cell transfusions, a total of 12 U. In March 1996, the patient was treated with cyclophosphamide (1 mg/kg/day). After 1 month of treatment, serum GPT levels increased to 60 IU/l. The dose of cyclophosphamide was reduced to 0.5 mg/kg/day. Two months after initiation of the therapy, the patient developed reticulocytosis and blood transfusion was not needed thereafter. During remission, the number of CD2+, CD3+, CD4-, and CD8+ lymphocytes decreased. Large granular lymphocytes decreased to less than 10% of peripheral blood. The monoclonal rearrangement of the TCR-beta chain gene in peripheral blood disappeared.
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Affiliation(s)
- M Masuda
- Department of Hematology, Tokyo Women's Medical College, Japan
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Suzuki S, Osaka Y, Nakai I, Yasumura T, Omori Y, Yamagata N, Shimazaki C, Oka T. Pure red cell aplasia induced by FK506. Transplantation 1996; 61:831-2. [PMID: 8607191 DOI: 10.1097/00007890-199603150-00026] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- S Suzuki
- Second Department of Surgery, Kyoto Prefectural University of Medicine, Japan
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Abstract
A case of a patient presenting with idiopathic concurrent erythrocytic and megakaryocytic aplasia is reported. The patient's response to immunosuppressive therapy and her bone marrow pathology clearly suggest an immune mechanism. Based on the lack of suppression of erythroid colony growth, several mechanisms are postulated. Well-established molecular and genetic evidence, along with clinical observations, suggests that a relationship exists between the erythrocytic and megakaryocytic cell lines. This may be related to a common bipotential stem cell or common cell surface markers. This case provides strong clinical evidence to support this relationship.
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Affiliation(s)
- B F Canavan
- Division of Hematology/Oncology, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, USA
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Baldus M, Möller M, Walter H, Brass H, Queisser W. A case of pure red cell aplasia: follow-up on different immunosuppressive regimens. THE CLINICAL INVESTIGATOR 1994; 72:1051-5. [PMID: 7711414 DOI: 10.1007/bf00577754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A 66-year-old patient was admitted to our hospital in January 1992 for further evaluation of severe normocytic anemia. Hemoglobin (Hb) was 3.5 g/dl, reticulocyte count 1%. Bone marrow showed a nearly complete lack of red cell precursors, thus favoring the diagnosis of acquired pure red cell aplasia (PRCA). Immunosuppressive therapy with prednisolone was started but had to be supplemented with azathioprine because of a further rapid decrease in Hb to 3.7 g/dl after an initial transfusion of 6 U red blood cells. However, with this regimen a renewed decrease in Hb to 6.6 g/dl was noted, and further transfusions were required. Therefore therapy was switched to cyclosporine A (CyA) while tapering off prednisolone. Four months after the initial diagnosis a positive parvovirus B19 IgM antibody was found. After the failure of hematological remission with three immunosuppressive regimens a course of high-dose intravenous immunoglobulins (IVIG) was administered in July 1992. Six weeks after IVIG therapy a peak hemoglobin concentration of 12.3 g/dl was noted, and further transfusion was not required. CyA was tapered off in October 1992. One month later CyA was reinstituted because of a relapse of PRCA but was unsuccessful until January 1993. At this time immunosuppressive CyA therapy was discontinued because of a periodontal abscess. In February 1993 a second IVIG infusion was given, and a second remission of PRCA was noted, showing an increase in hemoglobin up to 14.5 g/dl by November 1993. At the last follow-up visit in February 1994 our patient was still in complete hematological remission.
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Affiliation(s)
- M Baldus
- Medizinische Klinik A, Klinikum der Stadt, Ludwigshafen am Rhein, Germany
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Kwong YL, Liang RH. Pure red cell aplasia successfully treated by cyclosporin A as the sole agent. Am J Hematol 1994; 47:148. [PMID: 8092138 DOI: 10.1002/ajh.2830470224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Ishiyama T, Akimoto Y, Ueno H, Kawakami K, Koike M, Tomoyasu S, Tsuruoka N. Spontaneous IL-2 production in vitro in two patients with pure red cell aplasia. Ann Hematol 1993; 67:249-52. [PMID: 8241349 DOI: 10.1007/bf01715056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We investigated spontaneous cytokine production in two patients with pure red cell aplasia (PRCA). The peripheral blood mononuclear cells (PBMNC) from two patients produced IL-2. Cyclosporin A (CyA) suppressed in vitro IL-2 production in one patient, but not in the other. Spontaneous IL-2 production disappeared in one patient 10 months after the start of CyA therapy. The patient for whom CyA therapy was stopped after the disappearance of spontaneous IL-2 production has remained in continuous remission for 1 year. The present case suggests that spontaneous IL-2 production in PBMNC might be an indicator of disease activity.
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Affiliation(s)
- T Ishiyama
- Department of Hematology, Showa University School of Medicine, Tokyo, Japan
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McLeod BC, Strauss RG, Ciavarella D, Gilcher RO, Kasprisin DO, Kiprov DD, Klein HG. Management of hematological disorders and cancer. J Clin Apher 1993; 8:211-30. [PMID: 8113208 DOI: 10.1002/jca.2920080404] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- B C McLeod
- Rush Medical College, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois
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Nakao S, Masaoka H, Shiobara S, Mori T, Matsuda T. Dramatic improvement of pure red cell aplasia refractory to combined cyclosporine and prednisolone therapy induced by prednisolone dose escalation. Br J Haematol 1991; 79:520-1. [PMID: 1751381 DOI: 10.1111/j.1365-2141.1991.tb08066.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- S Nakao
- Third Department of Internal Medicine, Kanazawa University School of Medicine, Japan
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