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Kashiv P, Malde S, Dubey S, Gupta S, Pawar T, Sejpal KN, Gurjar P, Pasari A, Balwani M, Bhawane A, Tolani P, Bawankule CP. A Case of Erythropoietin (EPO)-Induced Pure Red Cell Aplasia and Its Treatment Efficacy With Desidustat. Cureus 2024; 16:e62022. [PMID: 38989377 PMCID: PMC11235398 DOI: 10.7759/cureus.62022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 06/09/2024] [Indexed: 07/12/2024] Open
Abstract
Pure red cell aplasia (PRCA), a rare hematological disorder marked by severe anemia and reticulocytopenia, results from the near absence of developing erythroid precursors in the otherwise normal bone marrow. This case report focuses on a 48-year-old female with chronic kidney disease (CKD) who received erythropoietin injections for CKD-related secondary anemia. Despite an initial positive response, a sudden drop in hemoglobin levels prompted investigations, revealing endogenous erythropoietin (EPO)-induced PRCA due to anti-EPO antibodies. In response, desidustat, an oral hypoxia-inducible factor-prolyl hydroxylase inhibitor, was successfully introduced as an alternative treatment. This led to a substantial and sustained improvement in hemoglobin levels, emphasizing the crucial role of swift diagnosis and intervention in EPO-induced PRCA cases. Administration method and storage conditions are noteworthy factors influencing recombinant human erythropoietin (rHuEPO) immunogenicity. The case underscores desidustat's emergence as a less immunogenic and effective alternative for anemia, marking a significant advancement, particularly in the context of this pioneering case in India showcasing its efficacy.
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Affiliation(s)
- Pranjal Kashiv
- Nephrology, Jawaharlal Nehru Medical College, Wardha, IND
| | - Sunny Malde
- Nephrology, Jawaharlal Nehru Medical College, Wardha, IND
| | - Shubham Dubey
- Nephrology, Jawaharlal Nehru Medical College, Wardha, IND
| | - Sushrut Gupta
- Nephrology, Jawaharlal Nehru Medical College, Wardha, IND
| | - Twinkle Pawar
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Kapil N Sejpal
- Nephrology, Jawaharlal Nehru Medical College, Wardha, IND
| | - Prasad Gurjar
- Nephrology, Jawaharlal Nehru Medical College, Wardha, IND
| | - Amit Pasari
- Nephrology, Saraswati Kidney Care Center, Nagpur, IND
- Nephrology, Jawaharlal Nehru Medical College, Wardha, IND
| | - Manish Balwani
- Nephrology, Saraswati Kidney Care Center, Nagpur, IND
- Nephrology, Jawaharlal Nehru Medical College, Wardha, IND
| | - Amol Bhawane
- Nephrology, All India Institute of Medical Sciences, Nagpur, Nagpur, IND
| | - Priyanka Tolani
- Internal Medicine, Jawaharlal Nehru Medical College, Wardha, IND
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Chen XM, Li H, Wu Y, Wang LL, Bai YJ, Shi YY. Case report: Dynamic antibody monitoring in a case of anti-recombinant human erythropoietin-mediated pure red cell aplasia with prolonged course after kidney transplantation. Front Immunol 2022; 13:1049444. [PMID: 36524109 PMCID: PMC9744924 DOI: 10.3389/fimmu.2022.1049444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/11/2022] [Indexed: 11/30/2022] Open
Abstract
Anti-erythropoietin (anti-EPO) antibody-mediated pure red cell aplasia (PRCA) is a rarely seen disease. Anti-EPO antibodies were mostly found in patients with chronic kidney disease who received recombinant human erythropoietin (rHuEPO) injections subcutaneously. The treatment against anti-EPO antibody-mediated PRCA included discontinuation of rHuEPO, immunosuppressive agents, intravenous immunoglobulin, plasmapheresis, or kidney transplantation. We reported a case of kidney transplant recipient with anti-EPO antibody-mediated PRCA, who had no trend of recovery after stopping rHuEPO, receiving regular induction and maintenance immunosuppressive regimens. He was further given 6 consecutive plasmapheresis sessions, cyclophosphamide, and adjusted maintenance immunosuppressive regimen into cyclosporine, sirolimus and prednisone. We monitored his anti-EPO antibody levels with a self-created simple mixing test. At 10 months post kidney transplant, his anti-EPO antibody finally turned negative, and his reticulocyte count dramatically increased. Cyclosporine, sirolimus and prednisone combined with roxadustat eventually alleviated the patient's anti-EPO antibody-mediated PRCA. Our self-created simple mixing test for anti-EPO antibody titer was very helpful in disease monitoring and therapeutic guidance.
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Affiliation(s)
- Xiao-Mei Chen
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hui Li
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yu Wu
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lan-Lan Wang
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yang-Juan Bai
- Department of Laboratory Medicine/Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China,*Correspondence: Yun-Ying Shi, ; Yang-Juan Bai,
| | - Yun-Ying Shi
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China,*Correspondence: Yun-Ying Shi, ; Yang-Juan Bai,
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Okahashi N, Kubo M, Hoshino E, Uchihara M, Amano I, Tanaka H. Successful Treatment of Antibody-mediated Pure Red Cell Aplasia Induced by Continuous Erythropoietin Receptor Activator with Prednisolone. Intern Med 2022; 61:2209-2213. [PMID: 34980800 PMCID: PMC9381349 DOI: 10.2169/internalmedicine.8823-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pure red cell aplasia (PRCA) associated with erythropoiesis-stimulating agents (ESAs), which were first reported in 1998, usually occurs with subcutaneous administration of epoetin alfa (Eprex®). Improvements in ESA storage, handling, and administration methods have reduced the PRCA incidence. Continuous erythropoietin receptor activator (CERA) is a third-generation ESA that is rarely reported to induce PRCA. We herein report a case of CERA-induced PRCA presenting with positive anti-erythropoietin (EPO) and anti-CERA antibodies, which was successfully treated with prednisolone. Clinicians should be aware of the possibility of antibody-mediated PRCA induced by an ESA in CKD patients with anemia with reticulocytopenia and low serum EPO levels.
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Affiliation(s)
- Nozomi Okahashi
- Department of Internal Medicine, Saiseikai Chuwa Hospital, Japan
| | - Masayuki Kubo
- Department of Hematology, Nara Medical University, Japan
| | - Ei Hoshino
- Department of Internal Medicine, Saiseikai Chuwa Hospital, Japan
| | | | - Itsuto Amano
- Department of Hematology, Nara Medical University, Japan
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Kwon HJ, Kim JH, Yoo DW, Kim TH, Yoon JH, Kim KH. Cutaneous leukocytoclastic vasculitis induced by continuous erythropoietin receptor activator. JAAD Case Rep 2021; 16:101-104. [PMID: 34553012 PMCID: PMC8441105 DOI: 10.1016/j.jdcr.2021.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Hyeok-Jin Kwon
- Department of Dermatology, College of Medicine, Dong-A University, Busan, Republic of Korea
| | - Jung-Hwan Kim
- Department of Dermatology, College of Medicine, Dong-A University, Busan, Republic of Korea
| | - Dong-Wha Yoo
- Department of Dermatology, College of Medicine, Dong-A University, Busan, Republic of Korea
| | - Tae-Hoon Kim
- Department of Dermatology, College of Medicine, Dong-A University, Busan, Republic of Korea
| | - Jung-Ho Yoon
- Department of Dermatology, College of Medicine, Dong-A University, Busan, Republic of Korea
| | - Ki-Ho Kim
- Department of Dermatology, College of Medicine, Dong-A University, Busan, Republic of Korea
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