Recombinant human erythropoietin in the treatment of anemia associated with human immunodeficiency virus (HIV) infection and zidovudine therapy. Overview of four clinical trials

Microbial Transglutaminase-Mediated Formation of Erythropoietin-Polyester Conjugates

Erythropoietin (EPO) is a glycoprotein hormone that has been used to treat anemia in patients with chronic kidney disease and in cancer patients who are receiving chemotherapy. Here, we investigated the accessibility of the glutamine (Gln, Q) residues of recombinant human erythropoietin (rHuEPO) towards a thermoresistant variant microbial transglutaminase (mTGase), TG¹⁶ with the aim of developing novel rHuEPO conjugates that may potentially enhance its biological efficacy. As a model bioconjugation, we studied the reactivity of rHuEPO towards TG¹⁶ with a low molar mass amine group containing substrate, monodansyl cadaverine (MDC). The reactions were carried out at a T_m of 54.3 °C, the transition temperature of rHuEPO. Characterization by SDS-PAGE and mass spectrometry confirmed the conjugates formation. Then, we examined the conjugation of rHuEPO with a biodegradable and biocompatible polyester, poly(D-sorbitol adipate) (PDSA). To achieve this, PDSA was enzymatically synthesized using lipase B from Candida antartica (CAL-B), chemically modified with side chains having free primary amine (NH₂) groups that can be acyl acceptor substrate of TG¹⁶, thoroughly characterized by ¹H NMR spectroscopy, and then applied for the TG¹⁶-mediated conjugation reaction with rHuEPO. rHuEPO conjugates generated by this approach were identified by SDS-PAGE proving that the amine-grafted PDSA is accepted as a substrate for TG¹⁶. The successful conjugation was further verified by the detection of high molar mass fluorescent bands after labelling of amine-grafted PDSA with rhodamine B-isothiocyanate. Overall, this enzymatic procedure is considered as an effective approach to prepare biodegradable rHuEPO-polymer conjugates even in the presence of N- and O-glycans.

Systematic review and meta-analysis assessing the knowledge and use of the female condom among Nigerians

Background

The female condom (FC) is a critical component in a comprehensive and sustainable approach to prevent HIV, other sexually transmitted infections and unintended pregnancies.

Objectives

This review provides comprehensive information about Nigerian's knowledge and use of FC.

Methods

We screened search output, evaluated study eligibility, and extracted data in duplicate. Data from similar studies were combined in a meta-analysis.

Results

There was a significantly (p < 0.0001) high-level of awareness amongst the respondents. However, the use of the FC was very low at 5.5% among female respondents. There was a significant (p < 0.0001) difference between FC awareness and use. The main reasons for FC use were prevention of unintended pregnancy (55%) and STIs/HIV (31%). We observed a significant difference between reasons of non-use of the FC [F (5, 13) = 5.195, P = 0.0077]. Furthermore, there were significant differences between the sources of information on FC [F (3, 8) = 32.89, P < 0.0001].

Conclusion

Despite the high levels of awareness, especially among the female respondents, the use of the FC has remained extremely low even among the young, educated undergraduate students. There is aneed for robust and consistent advocacy to make the FC available and affordable.

Clinical Indications of Recombinant Human Erythropoietin in a Single Center: A 10-Year Retrospective Study

In the 1980s, recombinant human erythropoietin (rhEPO) began to be used in clinical practice. In this study, the clinical application of rhEPO from single-center in recent ten years was reviewed, and the scope of indications and clinical efficacy were evaluated. The medical records of 35829 in-patients who were treated with rhEPO in the first Medical Center of the Chinese PLA General Hospital from 2009 to 2018 were collected. According to the scope of indications approved by CFDA (China Food and Drug Administration), curative effect and off-label of rhEPO were analyzed. Of the 35829 patients, 19013 (53.1%) were male and 16816 (46.9%) were female, with an average age of (52.1 ± 18.6) years. The usage of rhEPO is increasing year by year. The overall effective rate was 53.1%. The number of patients who met the indications accounted for 67.2%, and the effective rate patients with indications and Off-label were 48.8% and 50.7%. Among the patients with irregular use of rhEPO perioperative imperfect laboratory examination patients accounted for the highest proportion (7.1%). The volume of RBC(s) (red blood cell(s)) transfusion in patients with rhEPO was significantly less than that in patients without rhEPO (p<0.05). The use of rhEPO Off-label is very common and has a certain curative effect. It can be used as evidence support for the update of the scope of indications. In addition, There are still irregular use of rhEPO and transfusion in clinic. The unreasonable use of rhEPO and transfusion should be further standardized to ensure the safety and effectiveness.

Multidrug-resistant tuberculosis (MDR-TB) and multidrug-resistant HIV (MDR-HIV) syndemic: challenges in resource limited setting

Tuberculosis (TB) is common among persons living with HIV. This public health concern is aggravated by infection with multidrug-resistant organisms and adverse effects of polypharmacy. There are few published cases of multidrug-resistant tuberculosis (MDR-TB) in multidrug-resistant HIV (MDR-HIV) infected patients. We report a case of a 29-year-old Filipino man with HIV on zidovudine (AZT)-containing antiretroviral therapy (ART) but was eventually shifted to tenofovir due to anaemia. He presented with left flank tenderness, which was found to be due to an MDR-TB psoas abscess, and for which second-line anti-TB treatment was started. HIV genotyping showed MDR-HIV infection susceptible only to AZT, protease inhibitors and integrase inhibitors. Subsequently, he developed neck abscess that grew Mycobacterium avium complex and was treated with ethambutol and azithromycin. ART regimen was revised to AZT plus lamivudine and lopinavir/ritonavir. Erythropoietin was administered for recurrent AZT-induced anaemia. Both abscesses resolved and no recurrence of anaemia was noted.

Thrombopoietin level predicts response to treatment with eltrombopag and romiplostim in immune thrombocytopenia

Thrombopoietin receptor agonists (TPO-RAs) are used to treat immune thrombocytopenia (ITP), but predicting clinical response to TPO-RAs before initiation is not possible. To determine whether endogenous TPO levels predict treatment response to TPO-RAs we performed a retrospective analysis of ITP patients with known baseline TPO levels who received TPO-RAs. Data was collected for ITP patients with a baseline TPO level treated with eltrombopag or romiplostim. Multiple logistic regression was used to model the probability of 3 classes of treatment response (overall, moderate, and superior) based on TPO level; receiver operating characteristic (ROC) analysis was performed to identify optimal TPO thresholds for response; correlations between TPO level and various response characteristics were analyzed. A total of 67 patients (37 receiving eltrombopag and 46 receiving romiplostim) were included. Logistic regression models demonstrated a significant predictive relation between TPO level and probability of all classes of response; per 10 pg/mL TPO increase, odds ratio for overall response to eltrombopag was 0.524 (95% CI 0.327, 0.837) and romiplostim was 0.905 (95% CI, 0.844, 0.970). TPO level was inversely correlated with all classes of response; for overall response, r = -0.719 (P < .001) for eltrombopag and r = -0.584 (P < .001) for romiplostim. ROC analysis identified TPO thresholds of ≤136 pg/mL (eltrombopag) and ≤209 pg/mL (romiplostim) as optimally discriminating between responders and nonresponders. Most non-responders had high TPO levels but did respond after addition of low-dose prednisone. In conclusion, TPO levels predict response to eltrombopag and romiplostim in ITP patients, with lower levels predicting improved probability and magnitude of response.

Seizures in Dialysis Patients Treated with Recombinant Erythropoietin. Review of the Literature and Guidelines for Prevention

Anemia is one of the major limitations to rehabilitation in patients with end-stage renal disease (ESRD). The efficacy of recombinant human erythropoietin (rHuEPO) in the treatment of renal anemia is well established. Nevertheless, rHuEPO therapy has been associated with serious untoward effects. There appears to be an increased risk of hypertension, not infrequently accompanied by hypertensive encephalopathy and seizures. The mechanism of hypertension remains uncertain. It is associated with an increase in blood viscosity, a reversal of hypoxic vasodilatation, and, possibly, a direct pressor effect of the hormone. Seizures, otherwise, may be the result of cerebral hypoperfusion and, finally, of a focal cerebral edema. The guidelines for rHuEPO treatment and prevention of associated convulsions are outlined. The possible convulsive risk induced by this treatment, even at low doses, particularly in patients with a previous history of seizures, is stressed.

Iron deficiency or anemia of inflammation? : Differential diagnosis and mechanisms of anemia of inflammation

Iron deficiency and immune activation are the two most frequent causes of anemia, both of which are based on disturbances of iron homeostasis. Iron deficiency anemia results from a reduction of the body’s iron content due to blood loss, inadequate dietary iron intake, its malabsorption, or increased iron demand. Immune activation drives a diversion of iron fluxes from the erythropoietic bone marrow, where hemoglobinization takes place, to storage sites, particularly the mononuclear phagocytes system in liver and spleen. This results in iron-limited erythropoiesis and anemia. This review summarizes current diagnostic and pathophysiological concepts of iron deficiency anemia and anemia of inflammation, as well as combined conditions, and provides a brief outlook on novel therapeutic options.

Clinical Evaluation of the BD FACSPresto™ Near-Patient CD4 Counter in Kenya

BACKGROUND

The BD FACSPresto™ Near-Patient CD4 Counter was developed to expand HIV/AIDS management in resource-limited settings. It measures absolute CD4 counts (AbsCD4), percent CD4 (%CD4), and hemoglobin (Hb) from a single drop of capillary or venous blood in approximately 23 minutes, with throughput of 10 samples per hour. We assessed the performance of the BD FACSPresto system, evaluating accuracy, stability, linearity, precision, and reference intervals using capillary and venous blood at KEMRI/CDC HIV-research laboratory, Kisumu, Kenya, and precision and linearity at BD Biosciences, California, USA.

METHODS

For accuracy, venous samples were tested using the BD FACSCalibur™ instrument with BD Tritest™ CD3/CD4/CD45 reagent, BD Trucount™ tubes, and BD Multiset™ software for AbsCD4 and %CD4, and the Sysmex™ KX-21N for Hb. Stability studies evaluated duration of staining (18-120-minute incubation), and effects of venous blood storage <6-24 hours post-draw. A normal cohort was tested for reference intervals. Precision covered multiple days, operators, and instruments. Linearity required mixing two pools of samples, to obtain evenly spaced concentrations for AbsCD4, total lymphocytes, and Hb.

RESULTS

AbsCD4 and %CD4 venous/capillary (N = 189/ N = 162) accuracy results gave Deming regression slopes within 0.97-1.03 and R2 ≥0.96. For Hb, Deming regression results were R2 ≥0.94 and slope ≥0.94 for both venous and capillary samples. Stability varied within 10% 2 hours after staining and for venous blood stored less than 24 hours. Reference intervals results showed that gender-but not age-differences were statistically significant (p<0.05). Precision results had <3.5% coefficient of variation for AbsCD4, %CD4, and Hb, except for low AbsCD4 samples (<6.8%). Linearity was 42-4,897 cells/μL for AbsCD4, 182-11,704 cells/μL for total lymphocytes, and 2-24 g/dL for Hb.

CONCLUSIONS

The BD FACSPresto system provides accurate, precise clinical results for capillary or venous blood samples and is suitable for near-patient CD4 testing.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02396355.

Haematological manifestations of human immune deficiency virus infection

Early in the human immunodeficiency virus (HIV) epidemic, infected patients presented to medical attention with striking abnormalities in each of the major blood cell lineages. The reasons for these derangements remain complex and multifactorial. HIV infects multipotent haematopoietic progenitor cells and establish latent cellular reservoirs, disturbs the bone marrow microenvironment and also causes immune dysregulation. These events lead to cytokine imbalances and disruption of other factors required for normal haematopoiesis. Activation of the reticulo-endothelial system can also result in increased blood cell destruction. The deleterious effects of medications, including first and second generation anti-retroviral agents, on haematopoiesis were well documented in the early years of HIV care; in the current era of HIV-care, the advent of newer and less toxic anti-retroviral drugs have had a more beneficial impact on haematopoiesis. Due to impaired regulation of the immune system and potential side effects of one or more anti-retroviral agents, there is also an increase in coagulation abnormalities such as thromboembolism, and less frequently, acquired disorders of coagulation including thrombotic thrombocytopenic purpura, immune thrombocytopenic purpura and acquired inhibitors of coagulation. In this article we review the epidemiology and aetiology of select non-oncological haematological disorders commonly seen in people living with HIV-acquired immune deficiency syndrome.

Pharmacokinetics and pharmacodynamics of recombinant human EPO-Fc fusion protein in vivo

In this study, the in vivo pharmacokinetics and pharmacodynamics of a novel recombinant human erythropoietin (rhEPO) Fc fusion protein, rhEPO-Fc, were studied in both rodents and rhesus monkeys. Animal models of anemia induced by irradiation, cyclophosphamide and partial renal ablation were used to evaluate therapeutic effects of rhEPO-Fc. We have demonstrated that serum half-life of rhEPO-Fc was 29.5 to 38.9 h at doses of 8, 25, 80 µg/kg in rhesus monkeys and 35.5 to 43.5 h at doses of 16, 50, 160 µg/kg in rats. In anemia animal models, rhEPO-Fc dose-dependently (7.5–30.0 µg/kg in mice, 5.4–21.4 µg/kg in rats and 5.0–10.0 µg/kg in rhesus monkeys) increased reticulocyte level, followed by an increase of RBC count, hemoglobin and hematocrit levels. At reduced intervention frequency of weekly treatments, rhEPO-Fc showed similar hematopoietic effects as compared with rhEPO given three times a week. These results indicated that rhEPO-Fc could potentially be used in treatment of anemia and warrants future clinical trials.

Erythropoietin use and abuse

Recombinant human erythropoietin (rhEPO) is arguably the most successful therapeutic application of recombinant DNA technology till date. It was isolated in 1977 and the gene decoded in 1985. Since then, it has found varied applications, especially in stimulating erythropoiesis in anemia due to chronic conditions like renal failure, myelodysplasia, infections like HIV, in prematurity, and in reducing peri-operative blood transfusions. The discovery of erythropoietin receptor (EPO-R) and its presence in non-erythroid cells has led to several areas of research. Various types of rhEPO are commercially available today with different dosage schedules and modes of delivery. Their efficacy in stimulating erythropoiesis is dose dependent and differs according to the patient's disease and nutritional status. EPO should be used carefully according to guidelines as unsolicited use can result in serious adverse effects. Because of its capacity to improve oxygenation, it has been abused by athletes participating in endurance sports and detecting this has proved to be a challenge.

Aberrant phenotypes of transgenic mice expressing dimeric human erythropoietin

BACKGROUND

Dimeric human erythropoietin (dHuEPO) peptides are reported to exhibit significantly higher biological activity than the monomeric form of recombinant EPO. The objective of this study was to produce transgenic (tg) mice expressing dHuEPO and to investigate the characteristics of these mice.

METHODS

A dHuEPO-expressing vector under the control of the goat beta-casein promoter, which produced a dimer of human EPO molecules linked by a 2-amino acid peptide linker (Asp-Ile), was constructed and injected into 1-cell fertilized embryos by microinjection. Mice were screened using genomic DNA samples obtained from tail biopsies. Blood samples were obtained by heart puncture using heparinized tubes, and hematologic parameters were assessed. Using the microarray analysis tool, we analyzed differences in gene expression in the spleens of tg and control mice.

RESULTS

A high rate of spontaneous abortion or death of the offspring was observed in the recipients of dHuEPO embryos. We obtained 3 founder lines (#4, #11, and #47) of tg mice expressing the dHuEPO gene. However, only one founder line showed stable germline integration and transmission, subsequently establishing the only transgenic line (#11). We obtained 2 F1 mice and 3 F2 mice from line #11. The dHuEPO protein could not be obtained because of repeated spontaneous abortions in the tg mice. Tg mice exhibited symptoms such as short lifespan and abnormal blood composition. The red blood cell count, white blood cell count, and hematocrit levels in the tg mice were remarkably higher than those in the control mice. The spleens of the tg mice (F1 and F2 females) were 11- and -21-fold larger than those of the control mice. Microarray analysis revealed 2,672 spleen-derived candidate genes; more genes were downregulated than upregulated (849/764). Reverse transcriptase-polymerase chain reaction (RT-PCR) and quantitative real-time PCR (qRT-PCR) were used for validating the results of the microarray analysis of mRNA expression.

CONCLUSIONS

In conclusion, dHuEPO tg mice caused excessive erythrocytosis that led to abnormal blood composition, short lifespan, and abnormal splenomegaly. Further, we identified 2,672 genes associated with splenomegaly by microarray analysis. These results could be useful in the development of dHuEPO-producing tg animals.

Treatment for anemia in people with AIDS

BACKGROUND

Anemia is common in persons with HIV infection and is associated with poor prognosis. There is a need to assess the effects of anemia treatments, and to determine whether these interventions are beneficial.

OBJECTIVES

To determine the efficacy and safety of treatments for anemia in people with HIV infection and AIDS.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 10, 2010), MEDLINE (1980-November 25, 2010), EMBASE (1980-November 25, 2010), LlLACS (1982 to November 25, 2010), Africa Index Medicus (up to November 9, 2010), ISI Web of Knowledge (2005 to October 9, 2010), Scirus (October 9, 2010) reference lists of relevant articles. We asked the Cochrane HIV/AIDS and Pregnancy and Childbirth Groups to check their Specialised Registers. We also checked the reference lists of all trials identified by the above methods.

SELECTION CRITERIA

Randomized trials assessing the effects of treatments for anemia in people diagnosed with HIV infection. There were no age restrictions.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed relevant studies for inclusion. Data extraction and quality assessment of relevant studies was performed by two authors and checked by the other two authors.

MAIN RESULTS

Six trials with a high risk of bias, including 537 patients, met the inclusion criteria. These trials only covered recombinant Human erythropoietin alfa (rHuEPO). Two of them including adult and paediatric participants (84 participants and 4 events) comparing rHuEPO to placebo did not reduce the risk of mortality with a follow up to 12 weeks (pooled RR 0.56, 95% confidence interval (CI) 0.08 to 4.05, I(2) = 0%). Any trials that compared rHuEPO to placebo did not show any benefit on hematological values response, number of patients transfused, or number of packed red cell transfused. Two trial compared the effects of two rHuEPO dosing regimens on hemoglobin value and quality of life, but the effects are unclear. Three RCT reported high risk of attrition bias; therefore, were not included in a meta-analysis.

AUTHORS' CONCLUSIONS

This updated Cochrane review provides evidence that rHuEPO compared with placebo does not reduce mortality, does not reduce transfusion requirements, did not increase hemoglobin levels, and did not improve quality of life in HIV-infected patients with anemia. The results are based on six RCTs with high risk of bias. Therefore prescription of this intervention for treating anemia in patients with AIDS is not justified, unless new evidence from a large high quality trial alters this conclusion.

Anemia in human immunodeficiency virus-infected and uninfected women in Rwanda

To determine the prevalence and risk factors of anemia among human immunodeficiency virus (HIV)-infected women in Rwanda and the influence of highly active antiretroviral therapy (HAART) on anemia, we analyzed 200 HIV-positive women and 50 HIV-negative women in a cross-sectional study. Clinical examinations and iron and vitamin B(12) assays were performed, and complete blood counts, serum folic acid levels, and CD4 cell count determined. The prevalence of anemia was significantly higher among HIV-positive women (29%) than among HIV-negative women (8%) (P < 0.001). Risk factors for anemia were lower body mass index (odds ratio [OR] = 3.4, 95% confidence interval [CI] = 2.4-4.1), zidovudine use (OR = 1.14, 95% CI = 1.01-1.29), lack of HAART (OR = 1.44, 95% CI = 1.21-1.67), oral candidiasis (OR = 1.4, 95% CI = 1.2-1.6), pulmonary tuberculosis (OR = 1.8, 95% CI = 1.7-2.2), cryptococcal meningitis (OR = 1.6, 95% CI = 1.21-1.8), Pneumocystis jiroveci pneumonia (OR = 1.41, 95% CI = 1.20-1.65) and CD4 lymphocyte count < 200 cells/μL (OR = 2.41, 95% CI = 2.01-3.07). The mean ± SD hemoglobin level of 10.9 ± 1.6 g/dL at HAART initiation significantly increased to 12.3 ± 1.5 g/dL in 8 months (P < 0.001). Anemia increases with HIV stage, and HAART is associated with a significant improvement in hemoglobin levels.

Landmark advances in the development of erythropoietin

This is a Minireview covering landmarks or milestones in the development of erythropoietin (EPO). Thirty-nine landmark advances have been identified, which cover the period 1863-2003. Several reports are included that directly support these original landmark advances. This Minireview also updates some of the advances in EPO research since my last Minireview update on EPO published in this journal in 2003. The areas of EPO research updated are: sites of production; purification, assay and standardization; regulation; action; use in anemias; extraerythropoietic actions; adverse effects; and blood doping. The new reports on the use of EPO in the therapy of myocardial infarction; stroke and other neurological diseases; diabetic retinopathy and other retinal diseases are also covered.

Cost-effectiveness of epoetin alfa and darbepoetin alfa in patients with chemotherapy-related anemia

Anemia frequently develops during cancer chemotherapy and contributes to a variety of adverse clinical outcomes. Correction of anemia has been shown to improve patient outcomes; however, the cost considerations of supportive-care interventions have also become increasingly important to payors. Chemotherapy-related anemia can be managed via red blood cell transfusion; however, inherent transfusion-associated risks (e.g., infectious transmission and immunosuppression) can be particularly problematic in patients with cancer. Epoetin alfa and darbepoetin alfa, alternatives to blood transfusion in patients with chemotherapy-related anemia, are both effective at improving hemoglobin levels and transfusion requirements in patients actively receiving chemotherapy. Determining the relative cost-effectiveness of these erythropoietic therapies is an active research area.

Use of agents stimulating erythropoiesis in digestive diseases

Anemia is the most common complication of inflammatory bowel disease (IBD). Control and inadequate treatment leads to a worse quality of life and increased morbidity and hospitalization. Blood loss, and to a lesser extent, malabsorption of iron are the main causes of iron deficiency in IBD. There is also a variable component of anemia related to chronic inflammation. The anemia of chronic renal failure has been treated for many years with recombinant human erythropoietin (rHuEPO), which significantly improves quality of life and survival. Subsequently, rHuEPO has been used progressively in other conditions that occur with anemia of chronic processes such as cancer, rheumatoid arthritis or IBD, and anemia associated with the treatment of hepatitis C virus. Erythropoietic agents complete the range of available therapeutic options for treatment of anemia associated with IBD, which begins by treating the basis of the inflammatory disease, along with intravenous iron therapy as first choice. In cases of resistance to treatment with iron, combined therapy with erythropoietic agents aims to achieve near-normal levels of hemoglobin/hematocrit (11-12 g/dL). New formulations of intravenous iron (iron carboxymaltose) and the new generation of erythropoietic agents (darbepoetin and continuous erythropoietin receptor activator) will allow better dosing with the same efficacy and safety.

Erythropoietin and erythropoiesis

Although the concept of a humoral regulator of erythropoiesis was introduced more than 100 years ago, its existence was first firmly established a little more than 50 years ago. This review briefly describes the historical development of information about erythropoietin. It then describes our current understanding of where erythropoietin is produced; the factors that regulate its rate of production; how erythropoietin acts at the cellular level to stimulate erythropoiesis; and its role in the regulation of the rate of erythropoiesis. Finally, it discusses the clinical uses of erythropoietin in the diagnosis and therapy of hematopoietic diseases.

Reduction in multi-lineage and erythroid progenitors distinguishes myelodysplastic syndromes from non-malignant cytopenias

We studied the diagnostic role of CFC assays in myelodysplastic syndromes (MDS) using CFC data from bone marrow (BM) and peripheral blood (PB) of 221 MDS patients, 51 patients with non-malignant causes of cytopenia and/or dysplasia and 50 normal controls. A consistent decrease in BM but not PB multi-lineage and erythroid progenitor frequencies was seen in patients with MDS compared to controls (P<0.05). Automated distinction showed a sensitivity of 87+/-6% and a specificity of 71+/-11% in classifying MDS patients. In conclusion, a defect in early hematopoietic progenitor activity, in particular erythroid activity, distinguishes MDS from non-MDS.

Altered iron metabolism in children with human immunodeficiency virus disease

BACKGROUND

Despite the high prevalence of altered iron metabolism in children with human immunodeficiency virus (HIV) disease, these alterations have not been well studied.

PROCEDURES

Twenty-six children with HIV disease underwent laboratory evaluation to determine the presence of anemia, and to classify the anemia as iron-deficiency anemia or anemia of chronic disease.

RESULTS

Half of the children had an alteration in iron metabolism: 6 were iron deficient, 4 had hyperferritinemia, and 3 demonstrated hyperferritinemia with iron deficiency.

CONCLUSIONS

These data indicate that alterations in iron metabolism are common even in the HAART era and warrant further study to identify individuals at risk for these alterations.

Impact of HIV-1 infection on the hematological recovery after clinical malaria

BACKGROUND

Anemia is the most frequent cytopenia in HIV-infected individuals and is often associated with malaria.

OBJECTIVE

To assess the impact of HIV-1 on the hematological recovery after a clinical malaria episode.

METHODS

In Ndola, Zambia, a region with high malaria and HIV prevalence, hemoglobin (Hb) was measured in 634 malaria patients 14 and 45 days after antimalarial treatment. Risk factors for hematological recovery were analyzed in a multivariate linear regression model.

RESULTS

At enrollment, HIV-1-infected malaria patients had lower Hb compared with HIV-1 uninfected (122.7 vs 136.0 g/L; P < 0.001). In both groups, mean Hb was significantly lower at day 14 posttreatment than day 0 (P < 0.0001) and significantly higher at day 45 than at day 14 (HIV-1 negative: P = 0.0001; HIV-1 infected: P = 0.005). HIV-1 was a risk factor for a larger Hb decrease until day 14 (P < 0.001) and slower recovery until day 45 (P = 0.048). When considering the whole 45-day follow-up period, mean Hb increased in the HIV-1-negative group (+3.54 g/L; 95% confidence interval: 1.37 to 5.70; P = 0.001) but not in the HIV-1-infected group (-0.72 g/L; 95% confidence interval: -3.85 to +2.40; P = 0.64). HIV-1 infection as such (P < 0.0001), not CD4 cell count (P = 0.46), was an independent risk factor for a slower hematological recovery.

CONCLUSIONS

HIV-1-infected malaria patients had a slower hematological recovery after successful parasite clearance. Malaria preventive measures should be targeted to this high-risk group.

Impact on hemoglobin of starting combination antiretroviral therapy with or without zidovudine in anemic HIV-infected patients

OBJECTIVE

To evaluate, among anemic patients with HIV, the impact on hemoglobin (Hb) of initiating zidovudine (AZT)-containing and non-AZT-containing combination antiretroviral therapy (cART).

METHODS

We used medical records data collected in 11 US cities from 1998 to 2004. Baseline anemia was described as mild (10 < Hb < or = 12 [women] or 14 [men] g/dL), moderate (8 < Hb < or = 10 g/dL), or severe (Hb < or = 8 g/dL). Improvement of anemia was a > or =1-g/dL increase in Hb, with a decrease in categoric severity. We excluded patients previously treated with erythropoietin or transfusion, and used Cox proportional hazards regression to describe factors associated with hazard of improvement of anemia.

RESULTS

For 1620 patients initiating cART, more than half (54%) of patients had improvement of anemia. Time to improvement of anemia was longer for those initiating AZT-containing regimens and blacks and was shorter for those with moderate and severe anemia or CD4 counts <200 cells/microL.

CONCLUSIONS

Most anemic patients initiating cART (with or without AZT) had increases in Hb-especially those with more severe anemia or immunosuppression. Initiation of AZT-containing cART may be considered, even for patients with preexisting anemia; however, improvement of anemia may be delayed for black patients and for patients with mild disease.

Does epoetin alfa improve health-related quality of life in chronically ill patients with anemia? Summary of trials of cancer, HIV/AIDS, and chronic kidney disease

OBJECTIVES

Anemia, defined as having low levels of hemoglobin (HGB), is caused by disease-related (e.g., bone marrow suppression, nutritional deficiency) or treatment-related (e.g., chemotherapy, antiretroviral therapy) factors. Although epoetin alfa has been shown to improve HGB outcomes in cancer, HIV/AIDS, and chronic kidney disease (CKD), these results have been viewed in isolation, rather than across populations. The purpose of this article is to review findings from trials that evaluated the impact of epoetin alfa on HGB and health-related quality of life (HRQL) across various populations with different underlying causes of anemia.

METHODS

A review of clinical trials published in English between January 1993 and September 2005. Searches were conducted using MEDLINE and EMBASE. Between- and within-group changes in HGB and HRQL were examined.

RESULTS

One hundred ten articles were retrieved and 18 were reviewed. Statistically significant improvements in HGB were generally seen (1) between groups for cancer patients receiving epoetin alfa compared with those receiving placebo or standard of care (SOC) (between-group differences in changes from baseline to end point ranging from 1.2 to 1.9 g/dl); and (2) within groups for HIV/AIDS and CKD patients receiving epoetin alfa (changes from baseline to end point of 2.5 and 2.9 g/dl and 2.7 g/dl, respectively). Statistically and clinically significant improvements in HRQL, particularly with regard to fatigue, were seen across chronic conditions based on the Linear Analog Scale Assessment energy scale; where improvements of at least 8 mm-considered clinically relevant-were generally seen (1) between groups for cancer patients receiving epoetin alfa compared with those receiving placebo or SOC (differences in changes from baseline to end point from 0.8 to 19.8 mm); and (2) within groups for HIV/AIDS and CKD patients receiving epoetin alfa (changes from baseline to end point of 23 and 25 mm and 28 mm, respectively).

CONCLUSIONS

Results of published clinical trials suggest that treatment of anemia associated with cancer, HIV/AIDS and CKD can have a significant impact on HRQL, particularly fatigue, and that this impact is both statistically and clinically significant.

Micronutrients in HIV-positive persons receiving highly active antiretroviral therapy

In HIV-infected persons, low serum concentrations of vitamins and minerals, termed micronutrients, are associated with an increased risk of HIV disease progression and mortality. Micronutrient supplements can delay HIV disease progression and reduce mortality in HIV-positive persons not receiving highly active antiretroviral therapy (HAART). With the transition to more universal access to HAART, a better understanding of micronutrient deficiencies and the role of micronutrient supplements in HIV-positive persons receiving HAART has become a priority. The provision of simple, inexpensive micronutrient supplements as an adjunct to HAART may have several cellular and clinical benefits, such as a reduction in mitochondrial toxicity and oxidative stress and an improvement in immune reconstitution. We reviewed observational and trial evidence on micronutrients in HIV-positive persons receiving HAART to summarize the current literature and suggest future research priorities. A small number of observational studies have suggested that some, but not all, micronutrients may become replete after HAART initiation, and few intervention studies have found that certain micronutrients may be a beneficial adjunct to HAART. However, most of these studies had some major limitations, including a small sample size, a short duration of follow-up, a lack of adjustment for inflammatory markers, and an inadequate assessment of HIV-related outcomes. Therefore, few data are available to determine whether HAART ameliorates micronutrient deficiencies or to recommend or refute the benefit of providing micronutrient supplements to HIV-positive persons receiving HAART. Because micronutrient supplementation may cause harm, randomized placebo-controlled trials are needed. Future research should determine whether HAART initiation restores micronutrient concentrations, independent of inflammatory markers, and whether micronutrient supplements affect HIV-related outcomes in HIV-positive persons receiving HAART.

Treatment for anemia in people with AIDS

BACKGROUND

Anemia is a common clinical disease in persons with HIV infection and is associated with poor prognosis. There is a need to assess the effects of anemia treatments, and to determine whether these interventions are beneficial.

OBJECTIVES

To determine the efficacy and safety of treatments for anemia in people with HIV infection and AIDS.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005), MEDLINE (1980-July 2005), EMBASE (1980-July 2005), LlLACS (1982 to July 2005), reference lists of relevant articles and contact with authors. See Cochrane HIV/AIDS Group search strategy.

SELECTION CRITERIA

Randomized trials assessing the effects of treatments for anemia in people diagnosed with HIV infection. There were no age restrictions.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed relevant studies for inclusion. Data extraction and quality assessment of relevant studies was performed by one author and checked by the other author.

MAIN RESULTS

We included four trials, but focused on the results based on three trials with acceptable attrition rate. None of the trials reported data on death. The two trials that compared recombinant human erythropoietin (rHuEPO) to placebo did not show any benefit on hematological values response, number of patients transfused, or number of packed red cell transfused. One trial compared the effects of two rHuEPO dosing regimens on hemoglobin value and quality of life, but the effects are unclear.

AUTHORS' CONCLUSIONS

There is a lack of reliable evidence on interventions for treating anemia in patients with HIV infection. This Cochrane review has found some evidence that rHuEPO reduces transfusion requirements, increases hemoglobin levels, and improves quality of life in HIV-infected patients with anemia. However, this is based on evidence from randomized trials with weak or poor methodological quality. There is a need for randomized trials of high methodological quality to evaluate the effect of interventions on anemia in persons infected with human immunodeficiency virus.

Natural history of anemia associated with interferon/ribavirin therapy for patients with HIV/HCV coinfection

The natural history of anemia related to interferon/ribavirin (IFN/RBV) treatment in patients with human immunodeficiency virus/hepatitis C virus (HIV/HCV) coinfection is not completely understood. The current 8-week, multicenter, observational study characterized anemia over the course of HCV treatment in patients with HIV/HCV coinfection. Eligible HIV/HCV coinfected patients were receiving care in community-based and academic institutions and were on stable antiretroviral therapy and initiating IFN/RBV therapy. Hb, sEPO, reticulocytes, transfusions, laboratory values (e.g., total bilirubin), and IFN and RBV dosages were monitored weekly. Ninety-one patients were analyzed (mean age, 46 years; 71% on HAART) and 53 patients completed the study. Mean Hb decreased significantly (5.0 g/dl) within 1 week of initiating IFN/RBV therapy (p = 0.0002); Hb nadir occurred at a median of 37 days. Maximum Hb decreases of > or =2.0 g/dl occurred in 56 (62%) patients and > or =3.0 g/dl occurred in 45 (49%) patients. Reticulocyte count increased within the first 2 weeks and sEPO peaked at week 3. Mean increase from baseline to week 2 in reticulocyte count and sEPO, respectively, was 1.3% (n = 74) and 45.0 mIU/ml (n = 80) (p < 0.0001 for each parameter), and from baseline to week 8 was 0.9% (n = 48) and 41.0 mIU/ml (n = 52) (p < or = 0.0001 for each parameter). Adverse events (AEs) were the most common reason for study discontinuation (66% of discontinuing patients). Among the 25 patients who discontinued due to AEs, 84% discontinued due to anemia (n = 21). Significant decreases in Hb were observed in HIV/HCV-coinfected patients within 1 week of initiating IFN/RBV therapy. sEPO and reticulocyte increases were blunted in response to anemia; Hb levels did not return to baseline values and anemia was a frequent reason for discontinuing the study.

Erythropoietin: an update on the therapeutic use in newborn infants and children

Recombinant human erythropoietin (epoetin) has become the most widely used cytokine in the world. Following the success of its use in patients with end-stage renal disease, the usefulness of epoetin in other anaemias was assessed, including paediatric patients, mainly newborns. The treatment or prevention of anaemia of prematurity with epoetin resulted in a significant reduction in the number of transfusions and donor exposure. A clear definition of which premature babies must receive therapy is yet to be established. Other indications in neonatal period include hyporegenerative and haemolytic anaemias. The potential for use of the nonhaematopoietic effects of epoetin in newborn infants is a novel and exciting issue. The role of epoetin as a tissue-protective factor for the CNS and intestinal mucosa is under exhaustive investigation. With the exception of chronic renal failure, in older children the efficacy of epoetin has not been evaluated as in adults. Although an impressive amount of studies were carried out during recent years in adult patients with cancer-related or HIV-infection-related anaemias, thus allowing clear conclusions to be established on its efficacy, only a few trials with a small number of patients have been reported in children. Up-to-date, results in paediatric patients suggest that epoetin therapy is as useful as in adult patients, but prospective, randomised trials including large number of patients are essential to achieve definitive conclusions.

The prolonged half-lives of new erythropoietin derivatives via peptide addition

Erythropoietin, or Epo, is a hematopoietic cytokine that promotes erythropoiesis, and recombinant human Epo has been used in the treatment of anemia in various chronic diseases. Here, we have constructed novel Epo derivatives with prolonged half-lives by adding peptides to the carboxy terminus of Epo without using linkers. The fused peptides were selected from the carboxy terminal region of human chorionic gonadotropin (hCG) or human thrombopoietin (hTpo), which promote the proper folding, secretion, and stabilization of bioactive glycoproteins. Addition of these peptides did not interfere with secretion or receptor binding, and significantly increased the in vivo half-life of human Epo, as measured by intravenous administration in rats. The plasma half-life of the Epo constructs was longest when the carboxy terminal 28 aa of the beta subunit of hCG was added (Epo-CGC), a half-life that was slightly longer than NESP (Aranesp), which is the most effective Epo product in current clinical use. The transformation of four Ser glycosylation sites to Ala on the CGC sequence also lengthened the plasma half-life of Epo, indicating that the in vivo stabilizing effect of the hCG peptide was due to both structures within the peptide itself and its O-glycosylations. The application of the carboxy terminal half of hTpo also resulted in remarkably reduced elimination of the Epo chimera (Epo-TpC), possibly due to protection by the TpC sequence. The in vivo hematopoietic activity of Epo derivatives in mice was consistent with their pharmacokinetic profiles. Therefore, these derivatives with prolonged half-lives may provide opportunities for developing new Epo therapeutics with less frequent administration.

Anemia and HIV in the antiretroviral era: potential significance of testosterone

Anemia, the most common hematological disorder in human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS), is associated with decreased quality of life and survival. Hypogonadism is prevalent in advanced HIV disease, however, low testosterone levels have not been customarily implicated in HIV-associated anemia. This study was undertaken to determine whether there is a relationship between testosterone levels and androgen use with anemia in HIV, and to characterize other clinical correlates of HIV-associated anemia. This was a cross-sectional, observational study of 200 HIV-positive patients at a public hospital HIV clinic from July 2000 to August 2001. A written questionnaire detailed previous and current medication use, opportunistic infections, and malignancies. Hematological and virological parameters, testosterone, and erythropoietin levels were measured; CD4(+) T lymphocyte count and viral load nadir and peak levels were obtained from the computerized medical record. Anemia was defined as hemoglobin <13.5 g/dl in men and <11.6 g/dl in women. Twenty-four percent of women and 28% of men were anemic. Anemia was associated with lymphopenia (adjusted OR 4.0, 95% CI 1.36-11.80), high erythropoietin levels (adjusted OR 7.73, 95% CI 2.92-20.48), and low testosterone levels (adjusted OR 3.27, 95% CI 1.01-10.60). Anemia was negatively associated with female sex (adjusted OR 0.30, 95% CI 0.11-0.85), current antiretroviral therapy (adjusted OR 0.43, 95% CI 0.20-0.95), current androgen use (adjusted OR 0.20, 95% CI 0.05-0.84), and macrocytosis (adjusted OR 0.23, 95% CI 0.09-0.61). Low testosterone levels may have a positive association and supplemental androgens a negative association with anemia in HIV disease.

Epoetin Alfa for Treatment of Anemia in HIV-Infected Patients

Despite the availability of highly active antiretroviral therapy and the resulting reduction in severe anemia associated with HIV infection, epoetin alfa has continued to play an important role in the management of HIV-infected patients. Mild-to-moderate anemia remains common, and its correction with epoetin alfa has resulted in significant improvements in quality of life, physical functioning, and possibly prolongation of survival. New research has demonstrated that epoetin alfa may have therapeutic potential beyond its ability to stimulate erythropoiesis due to its neuroprotective and antiapoptotic properties. Current and future research will further clarify the role of epoetin alfa in the clinical management of the HIV-infected population.

Once-weekly epoetin alfa improves quality of life and increases hemoglobin in anemic HIV+ patients

This prospective, open-label, multicenter trial evaluated the effects of once-weekly (qw) epoetin alfa on quality of life (QOL) and hemoglobin (Hb) levels in anemic human immunodeficiency virus (HIV)-infected adult receiving antiretroviral therapy. A total of 650 patients with Hb < or = 11 g/dl received epoetin alfa 40,000 U qw subcutaneously, with dose escalation to 60,000 qw if Hb increase was <1 g/dl after 4 weeks. The linear Analog Scale Assessment (LASA) overall QOL score, LASA energy score, and LASA activity score each significantly improved from baseline to final measurement (p < 0.0001 for each parameter). Improvements in the Medical Outcomes Study (MOS)-HIV physical and mental health summary scores were also significant (p < 0.0001), and coincided with Hb increases. Mean Hb increased from baseline to final measurement by 2.5 g/dl (95% CI: 2.3, 2.6 g/dl; p < 0.0001). Objective hematological response rate, defined as a > or = 1 g/dl Hb increase from baseline to week 8, was 86%. Hemoglobin increased significantly in all subgroups of race, zidovudine use, CD4+ cell count, and viral load. Once-weekly epoetin alfa was well tolerated. Once-weekly epoetin alfa is effective in improving QOL and Hb measures.

Anemia and its treatment and outcomes in persons infected with human immunodeficiency virus

BACKGROUND

Anemia is a common comorbidity with HIV. Before the highly active antiretroviral therapy (HAART) era, anemia was found to be associated with decreased survival. This study examined the prevalence of anemia since HAART's availability and the associations between anemia treatments and survival.

STUDY DESIGN AND METHODS

Anemia prevalence in a cohort of HIV-infected persons was described. In a smaller cohort of HIV-infected anemic patients, survival was modeled with a time-dependent proportional hazards regression model adjusting for CD4+ T-lymphocyte count, plasma HIV RNA concentration load, hemoglobin (Hb) level, and other factors.

RESULTS

Anemia (Hb level < 10.5 g/dL, or physician diagnosis) decreased from 13 to 5 percent (p < 0.05) in 1996 through 2001. Anemia prevalence was highest (24-35%) and did not decrease among patients with CD4 count less than 100 cells per mL. In total, 216 severely anemic HIV-infected individuals (mean Hb level, 8.1 g/dL) followed for a median of 13 months had a 37-percent mortality rate. Of these, 22 percent were untreated (13% mortality rate), 42 percent received transfusion alone (52% mortality), 12 percent received epoetin alfa alone (19% mortality), and 24 percent received both (47% mortality). Transfusion was associated with a threefold excess mortality risk, but epoetin alfa prescription was not associated with mortality.

CONCLUSION

The prevalence of anemia decreased in the HAART era, and transfusion was positively associated with risk of death, suggesting limiting use of transfusions in nonemergency situations.

Prevalence and outcomes of anemia in individuals with human immunodeficiency virus: a systematic review of the literature

In patients with human immunodeficiency virus (HIV), anemia is a commonly encountered hematologic abnormality that has a significant impact on clinical outcomes and quality of life (QOL). This review describes the prevalence of anemia in several populations of patients with HIV and the effects of anemia on survival, morbidity, disease progression, transfusion requirements, and QOL. The prevalence of anemia in HIV disease varies considerably, ranging from 1.3% to 95%: it depends on several factors, including the stage of HIV disease, sex, age, pregnancy status, and injection-drug use as well as the definition of anemia used. In general, as HIV disease progresses, the prevalence and severity of anemia increase. Anemia is also more prevalent in HIV-positive women, children, and injection-drug users than in HIV-negative women, children, and injection-drug users. Anemia has been shown to be a statistically significant predictor of progression to the acquired immunodeficiency syndrome and is independently associated with an increased risk of death in patients with HIV. Treatment of anemia with epoetin-alpha has resulted in significantly fewer patients requiring transfusion as well as decreases in the mean number of units of blood transfused. Resolution of HIV-related anemia has been shown to improve QOL, physical functioning, energy, and fatigue in individuals with HIV. More recently, the use of highly active antiretroviral therapy has also been associated with a significant increase in hemoglobin concentrations and a decrease in the prevalence of anemia.

Management of anemia of chronic disease in patients with the human immunodeficiency virus

Anemia is the most frequently encountered hematologic complication in human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome. The prevalence estimates vary widely with the severity of HIV disease. Data suggest that treatment with highly active antiretroviral therapy may have a positive impact on reducing the prevalence of anemia of chronic disease in patients infected with HIV. Anemia consistently has been shown to be a predictor of decreased survival, and treatment plays an important role in improving patients' survival and quality of life (e.g., fatigue and dementia). Addressing potential underlying reversible causes and treating the chronic anemia are important strategies in the management of anemia. Erythropoietin therapy should be considered a first-line treatment, and blood transfusions should be limited to situations requiring immediate correction of hemoglobin levels.

Erythropoietin treatment in the neuropsychiatric porphyrias

BACKGROUND

In a previous report, 31 patients with neuropsychiatric porphyria were studied and nine of these patients were anaemic in association with inappropriately low serum erythropoietin levels. We were also able to demonstrate that treatment with erythropoietin in non-porphyric patients (mainly diabetic patients with autonomic neuropathy) significantly reduced urinary delta-aminolaevulinic acid levels.

METHODS

We treated six porphyric patients, five of whom were anaemic, with recombinant human erythropoietin (1000-2000 IU thrice weekly). They were all in clinical but not biochemical remission. Full blood count, including reticulocytes and platelets, urinary delta-aminolaevulinic acid, porphobilinogen and total porphyrins were measured monthly. Baseline serum ferritin, vitamin B(12), folate and C-reactive protein levels were all within the normal range and serum creatinine did not exceed 126 micromol/l.

RESULTS

After 3 months of treatment, the average baseline haemoglobin increased significantly (p=0.01). When treatment was stopped, the haemoglobin decreased and after 3 months pre-treatment, haemoglobin levels were reached. Urinary delta-aminolaevulinic acid, porphobilinogen and porphyrin levels all tended to decrease during treatment with erythropoietin, but the difference between baseline and 3 months of erythropoietin was statistically significant only for porphobilinogen (p=0.03). The severity of porphyria attacks was reduced and the quality of life increased during treatment with erythropoietin.

CONCLUSION

We conclude that in some porphyric patients treatment with erythropoietin reduces urinary delta-aminolaevulinic acid, porphobilinogen and porphyrin levels with an increase in well-being and a reduction in the severity of porphyria attacks.

Once-Weekly Epoetin Alfa Dosing Is as Effective as Three Times–Weekly Dosing in Increasing Hemoglobin Levels and Is Associated With Improved Quality of Life in Anemic HIV-Infected Patients

BACKGROUND

Anemia is prevalent in HIV-positive patients despite lower doses of zidovudine used in highly active antiretroviral therapy. Previously, epoetin alfa has been administered 3 times weekly (TIW). We compared the hematologic and quality of life (QOL) effects and tolerability of the more convenient once-weekly (QW) regimen with TIW epoetin alfa in anemic HIV-positive patients.

METHODS

Two hundred eighty-five anemic (hemoglobin [Hb] <12 g/dL) HIV-positive adults receiving stable antiretroviral therapy were enrolled in this 16-week, randomized, multicenter study. Enrolled patients were randomized to receive epoetin alfa doses of 40,000 to 60,000 U QW or 100 to 300 U/kg TIW.

RESULTS

Two hundred seventy-two patients were evaluable for efficacy. Both epoetin alfa dosing schedules produced significant Hb level increases by week 2 (mean Hb increase of 1.3 g/dL [QW] and 1.0 g/dL [TIW]; P < 0.0001) that continued to increase until week 8 and were maintained until study completion, with no significant difference between treatment groups at final Hb measurement (mean Hb increase of 2.9 g/dL [QW] and 2.5 g/dL [TIW]). All QOL parameters improved significantly (P < 0.05) from baseline by week 8 in both groups, with no significant differences between groups at week 16. Both dosing schedules were well tolerated.

CONCLUSIONS

QW dosing of epoetin alfa is as effective as TIW dosing in increasing Hb levels, which was associated with improved QOL in anemic HIV-positive patients. QW dosing should also offer added convenience for patients and caregivers.

Hepatitis C Virus/HIV Coinfection: A New Challenge for Nurses in AIDS Care

HIV-infected patients are living longer owing to effective treatment with highly active antiretroviral therapy (HAART). As a result, the extent and impact of hepatitis C virus (HCV) infection in this patient population are now becoming apparent. HIV infection accelerates the progression of HCV to cirrhosis, endstage liver disease, and death. The presence of each disease also influences treatment of the other, and appropriate management of side effects (e.g., anemia, neutropenia, depression) is crucial for treatment success. The HIV nurse is well positioned to treat, counsel, and support the HIV/HCV-coinfected patient by encouraging screening and providing education on the side effects of treatment, the means of managing side effects, and the resources available to assist in problems of substance abuse and depression.

Hematologic disorders associated with hepatitis C virus infection and their management

More than 4 million people in the United States are infected with hepatitis C virus (HCV). During the next 20-30 years, the burden of HCV-related mortality and morbidity will likely double. To date, the most effective treatment for chronic HCV infection is the combination of either interferon (IFN)-alpha or pegylated IFN-alpha and ribavirin. For a sustained virologic response, treatment adherence and dose maintenance are essential. However, both IFN-alpha and ribavirin induce hematologic toxicity, such as anemia, neutropenia, and thrombocytopenia, which can compromise treatment adherence and dose maintenance and could, therefore, potentially influence outcomes. Although there are currently no approved treatments for hematologic complications of HCV therapy, studies have shown that hematopoietic growth factors can provide significant benefits. This review highlights the pharmacology, risks, and benefits of recombinant hematopoietic growth factor therapy in HCV-infected patients.

Recombinant erythropoietin in clinical practice

The introduction of recombinant human erythropoietin (RHuEPO) has revolutionised the treatment of patients with anaemia of chronic renal disease. Clinical studies have demonstrated that RHuEPO is also useful in various non-uraemic conditions including haematological and oncological disorders, prematurity, HIV infection, and perioperative therapies. Besides highlighting both the historical and functional aspects of RHuEPO, this review discusses the applications of RHuEPO in clinical practice and the potential problems of RHuEPO treatment.