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Hirai K, Ookawara S, Miyazawa H, Ito K, Ueda Y, Kaku Y, Hoshino T, Kimura SI, Yoshida I, Kakuta S, Morishita Y, Tabei K. Successful treatment of a hemodialyzed patient with pure red cell aplasia associated with epoetin beta pegol therapy with cyclosporine. CEN Case Rep 2017; 5:78-82. [PMID: 28509169 DOI: 10.1007/s13730-015-0196-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 09/03/2015] [Indexed: 11/30/2022] Open
Abstract
A 42-year-old man with end-stage renal failure had been receiving hemodialysis therapy since April 2009. Initially, darbepoetin alfa was administered to treat his renal anemia. After treatment was switched to epoetin beta pegol, the patient's hemoglobin levels rapidly decreased. He was diagnosed with pure red cell aplasia (PRCA) based on the results of a bone marrow examination. Epoetin beta pegol was strongly suspected to be the cause of the PRCA, and although he tested negative for anti-epoetin beta pegol antibodies, epoetin beta pegol was discontinued and cyclosporine therapy was initiated. Thereafter, his hemoglobin levels increased, and his anemia dramatically improved after 3 months.
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Affiliation(s)
- Keiji Hirai
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Susumu Ookawara
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan.
| | - Haruhisa Miyazawa
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Kiyonori Ito
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Yuichiro Ueda
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Yoshio Kaku
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Taro Hoshino
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Shun-Ichi Kimura
- Division of Hematology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Izumi Yoshida
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | | | - Yoshiyuki Morishita
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Kaoru Tabei
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
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Rossert J, Yue S, Smirnakis K, Mytych DT, Johnson L, Kouchakji E, Casadevall N. Risk of pure red cell aplasia in patients with hepatitis C receiving antiviral therapy and an erythropoiesis-stimulating agent. Clin Gastroenterol Hepatol 2014; 12:341-5. [PMID: 24120841 DOI: 10.1016/j.cgh.2013.09.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 09/20/2013] [Accepted: 09/21/2013] [Indexed: 02/07/2023]
Abstract
Antibody-mediated pure red cell aplasia (PRCA) has been primarily observed in patients with chronic kidney disease treated with an erythropoiesis-stimulating agent (ESA); only a few anecdotal cases have been reported in other patient populations. We searched the Amgen Global Safety Adverse Event Database and identified 14 patients with hepatitis C who developed severe anemia, anti-erythropoietin antibodies, and bone marrow biopsy-proven PRCA, while receiving interferon therapy (with or without ribavirin) and an ESA. During the follow-up period and after ESA treatment stopped, 11 patients no longer required transfusions and 3 did. Analysis of antibody isotypes showed that, contrary to reports of patients with chronic kidney disease, immunoglobulin G1 was the predominant isotype rather than immunoglobulin G4 (immunoglobulin G4 was detected in only 1 of 6 patients). Epitope mapping showed the anti-erythropoietin antibodies bound domains required for receptor binding. Therefore, the potential benefits of ESA therapy must be weighed against the risk for PRCA in patients with hepatitis C who are receiving treatment with interferon and ribavirin.
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Affiliation(s)
- Jerome Rossert
- Clinical Development, Amgen Inc, Thousand Oaks, California
| | - Susan Yue
- Global Safety, Amgen Inc, Thousand Oaks, California
| | | | - Daniel T Mytych
- Clinical Immunology and Biologic Sample Management, Amgen Inc, Thousand Oaks, California
| | | | | | - Nicole Casadevall
- AP-HP, INSERM U 1009 and Pierre and Marie Curie University, Paris, France.
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Pure red cell aplasia caused by ribavirin and interferon treatment. Clin J Gastroenterol 2011; 4:313-317. [PMID: 26189631 DOI: 10.1007/s12328-011-0235-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 05/12/2011] [Indexed: 10/17/2022]
Abstract
Anemia is a common complication of hepatitis C (HCV), and antiviral treatment can further increase this risk. We present the case of a 59-year-old man with HCV treated with ribavirin and pegylated interferon alpha (INF-α) who presented with severe anemia. Two months after initiating treatment his hemoglobin dropped from 14.2 to 5.0 g/dL. There was no evidence of bleeding or hemolysis, and a bone marrow biopsy revealed pure red cell aplasia (PRCA). Evaluations for acute cytomegalovirus and parvovirus B19 were negative. There was no evidence of malignancy or thymoma. The INF-α and ribavirin treatment were determined to have caused the PRCA, and withdrawal of the medications led to PRCA remission. INF-α and ribavirin have become the standard treatment for HCV. While these medications offer a potential cure, they are often poorly tolerated due to frequent side effects including anemia. Patients who are receiving treatment with ribavirin and INF-α warrant close monitoring for development of anemia, and PRCA should be considered in all patients in whom reticulocytopenic anemia develops.
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Chang CS, Yan SL, Lin HY, Yu FL, Tsai CY. Pure red cell aplasia caused by pegylated interferon-α-2a plus ribavirin in the treatment of chronic hepatitis C. World J Gastroenterol 2011; 17:2155-8. [PMID: 21547138 PMCID: PMC3084404 DOI: 10.3748/wjg.v17.i16.2155] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Revised: 01/18/2011] [Accepted: 01/25/2011] [Indexed: 02/06/2023] Open
Abstract
Pure red cell aplasia (PRCA) is a rare hematological disorder which is characterized by severe anemia, reticulocytopenia and almost complete absence of erythroid precursors in bone marrow. The pathophysiology of PRCA may be congenital or acquired. To our knowledge, there is only one case report in the English literature of PRCA after pegylated interferon combination therapy for chronic hepatitis C. We report a second case of PRCA after pegylated interferon combination treatment for chronic hepatitis C. The diagnosis of PRCA was confirmed by the typical findings of bone marrow biopsy. The possible etiologies of our case are also discussed in this paper.
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Schecter JM, Mears JG, Alobeid B, Gaglio PJ. Anti-erythropoietin antibody-mediated pure red cell aplasia in a living donor liver transplant recipient treated for hepatitis C virus. Liver Transpl 2007; 13:1589-92. [PMID: 17969182 DOI: 10.1002/lt.21332] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
After liver transplantation, reinfection of the newly engrafted liver with hepatitis C virus is essentially universal in patients who are viremic at the time of transplantation. Treatment with interferon preparations with or without ribavirin is recommended in patients with marked histologic injury; however, hematologic toxicity associated with therapy has been reported, which is usually treated with growth factor support, including erythropoietin analogues. We present the first reported case of anti-erythropoietin antibody-mediated pure red cell aplasia arising in the setting of hepatitis C virus therapy in a patient who underwent living donor liver transplantation.
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Affiliation(s)
- Jordan M Schecter
- Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, NY, USA
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Stravitz RT, Chung H, Sterling RK, Luketic VA, Sanyal AJ, Price AS, Purrington A, Shiffman ML. Antibody-mediated pure red cell aplasia due to epoetin alfa during antiviral therapy of chronic hepatitis C. Am J Gastroenterol 2005; 100:1415-9. [PMID: 15929778 DOI: 10.1111/j.1572-0241.2005.41910.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Anemia frequently complicates the treatment of chronic hepatitis C with interferon and ribavirin (RVN), requiring dose reduction and jeopardizing sustained virologic response. Increasingly, epoetin alfa is used to prevent anemia in this setting. Below, we report the first case of pure red cell aplasia (PRCA) in a patient with chronic hepatitis C who received epoetin alfa (Procrit) to manage anti-viral treatment-induced anemia. Red blood cell transfusion-dependence developed 16 wk after the patient was started on peginterferon alfa-2b and RVN for chronic hepatitis C despite the simultaneous administration of epoetin alfa and subsequent discontinuation of the antiviral medications. Bone marrow biopsy was consistent with PRCA. High-titer erythropoietin antibodies, assayed by two methods, appeared shortly after epoetin alfa was administered, and were associated with a decline in serum erythropoietin to undetectable levels. Erythropoietin antibodies directed toward epoetin alfa were shown to cross react with darbepoetin alfa (Aranesp), and a neutralization assay confirmed that they inhibited cell growth in the presence of erythropoietin. Transfusion-dependence resolved approximately 16 wk after discontinuing epoetin alfa, and 6 wk after starting danazol. PRCA caused by the development of erythropoietin antibodies is a potentially life-threatening complication of administering epoetin alfa to prevent the anemia associated with antiviral therapy in patients with chronic hepatitis C.
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Affiliation(s)
- R Todd Stravitz
- Section of Hepatology, Division of Gastroenterology and the Division of Hematology/Oncology, Virginia Commonwealth University Medical Center, Richmond, Virginia 23298-0341, USA
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Shuster J. New Antifungal as a Potential Cause of Severe Thrombocytopenia: Pancreatitis Due to ACE Inhibitor: Recurrent Hepatitis Due to Cetirizine: Long-Term Cardiovascular Risks Associated with Protease Inhibitors: Pure Red Cell Aplasia and Epoetin Therapy: Pure Red Cell Aplasia Redux: Interferon Therapy: Excellent Drug Reaction Reviews. Hosp Pharm 2004. [DOI: 10.1177/001857870403901203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this feature is to heighten awareness of specific adverse drug reactions (ADRs), to discuss methods of prevention, and to promote reporting of ADRs to the FDA's medWatch program (800-FDA-1088). If you have reported an interesting preventable ADR to medWatch, please consider sharing the account with our readers. In 2004, ISMP is celebrating the 10th anniversary of its incorporation as a nonprofit organization. The Institute represents more than 20 years of experience in helping health care practitioners keep patients safe and continues to lead efforts to improve the medication use process.
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Affiliation(s)
- Joel Shuster
- Temple University School of Pharmacy, Philadelphia, PA; Clinical Pharmacist, Episcopal Hospital, Philadelphia; and Clinical Advisor and Trustee, Institute for Safe Medication Practices, Huntingdon Valley, PA 19006
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