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Improvement in erythropoieis-stimulating agent-induced pure red-cell aplasia by introduction of darbepoetin-α when the anti-erythropoietin antibody titer declines spontaneously.

Lee H, Yang J, Kim H, Kwon JW, Oh KH, Joo KW, Kim YS, Ahn C, Han JS, Kim S - J. Korean Med. Sci. (2010)

Bottom Line: Anti-erythropoietin antibodies usually cross-react with all kinds of recombinant erythropoietins; therefore, erythropoiesis-stimulating agent (ESA)-induced pure red-cell aplasia (PRCA) is not rescued by different ESAs.Interestingly, anti-erythropoietin antibodies were still detectable, although their concentration was too low for titration.In conclusion, darbepoetin-α can improve ESA-induced PRCA when the anti-erythropoietin antibody titer declines and its neutralizing capacity is lost.

View Article: PubMed Central - PubMed

Affiliation: Divison of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.

ABSTRACT
Anti-erythropoietin antibodies usually cross-react with all kinds of recombinant erythropoietins; therefore, erythropoiesis-stimulating agent (ESA)-induced pure red-cell aplasia (PRCA) is not rescued by different ESAs. Here, we present a case of ESA-induced PRCA in a 36-yr-old woman with chronic kidney disease, whose anemic condition improved following reintroduction of darbepoetin-α. The patient developed progressive, severe anemia after the use of erythropoietin-α. As the anemia did not improve after the administration of either other erythropoietin-α products or erythropoietin-β, all ESAs were discontinued. Oxymetholone therapy failed to improve the transfusion-dependent anemia and a rechallenge with ESAs continuously failed to obtain a sustained response. However, her anemia improved following reintroduction of darbepoetin-α at 3 yr after the initial diagnosis. Interestingly, anti-erythropoietin antibodies were still detectable, although their concentration was too low for titration. In conclusion, darbepoetin-α can improve ESA-induced PRCA when the anti-erythropoietin antibody titer declines and its neutralizing capacity is lost.

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Related in: MedlinePlus

Bone marrow biopsy findings. (A) Bone marrow section, The cellularity is 0-20% which is hypocellular for age. Trilineage hematopoiesis is markedly decreased, and the decrease of erythropoiesis is remarkable. Plasma cells, lymphocytes and eosinophils are unremarkable. Foreign cells and granulomata are absent, H&E stained, ×100. (B) A megakaryocyte and myeloid precursor cells are observed, but no erythroid precursor cells are observed, H&E stained, ×1,000.
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Figure 1: Bone marrow biopsy findings. (A) Bone marrow section, The cellularity is 0-20% which is hypocellular for age. Trilineage hematopoiesis is markedly decreased, and the decrease of erythropoiesis is remarkable. Plasma cells, lymphocytes and eosinophils are unremarkable. Foreign cells and granulomata are absent, H&E stained, ×100. (B) A megakaryocyte and myeloid precursor cells are observed, but no erythroid precursor cells are observed, H&E stained, ×1,000.

Mentions: Initial laboratory test values on admission were as follows: leukocyte count, 4,610 cells/µL; Hb, 5.4 g/dL; platelet count, 113,000 cells/µL; reticulocytes, 0.27%; total iron binding capacity, 220 µg/dL (39.38 µM/L); ferritin, 1,760 µg/L; iron, 201 µg/dL (35.98 µM/L); parathyroid hormone, 23 ng/L; blood urea nitrogen, 83 mg/dL (29.63 mM/L); creatinine, 12.3 mg/dL (1,087.32 µM/L); C-reactive protein, 0.75 mg/dL. Serologic tests for hepatitis viruses, cytomegalovirus, Epstein-Barr virus, human immunodeficiency virus, and parvovirus B19 were all negative. Thoracic computed tomographic scans or abdominal sonography showed no evidence of an abnormal mass such as thymoma or lymphoma. Bone marrow examination showed reduced cellularity (0-20%) and severe erythroid hypoplasia, whereas thrombopoiesis was in the low normal range and granulopoiesis was normal, findings consistent with PRCA (Fig. 1).


Improvement in erythropoieis-stimulating agent-induced pure red-cell aplasia by introduction of darbepoetin-α when the anti-erythropoietin antibody titer declines spontaneously.

Lee H, Yang J, Kim H, Kwon JW, Oh KH, Joo KW, Kim YS, Ahn C, Han JS, Kim S - J. Korean Med. Sci. (2010)

Bone marrow biopsy findings. (A) Bone marrow section, The cellularity is 0-20% which is hypocellular for age. Trilineage hematopoiesis is markedly decreased, and the decrease of erythropoiesis is remarkable. Plasma cells, lymphocytes and eosinophils are unremarkable. Foreign cells and granulomata are absent, H&E stained, ×100. (B) A megakaryocyte and myeloid precursor cells are observed, but no erythroid precursor cells are observed, H&E stained, ×1,000.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2967010&req=5

Figure 1: Bone marrow biopsy findings. (A) Bone marrow section, The cellularity is 0-20% which is hypocellular for age. Trilineage hematopoiesis is markedly decreased, and the decrease of erythropoiesis is remarkable. Plasma cells, lymphocytes and eosinophils are unremarkable. Foreign cells and granulomata are absent, H&E stained, ×100. (B) A megakaryocyte and myeloid precursor cells are observed, but no erythroid precursor cells are observed, H&E stained, ×1,000.
Mentions: Initial laboratory test values on admission were as follows: leukocyte count, 4,610 cells/µL; Hb, 5.4 g/dL; platelet count, 113,000 cells/µL; reticulocytes, 0.27%; total iron binding capacity, 220 µg/dL (39.38 µM/L); ferritin, 1,760 µg/L; iron, 201 µg/dL (35.98 µM/L); parathyroid hormone, 23 ng/L; blood urea nitrogen, 83 mg/dL (29.63 mM/L); creatinine, 12.3 mg/dL (1,087.32 µM/L); C-reactive protein, 0.75 mg/dL. Serologic tests for hepatitis viruses, cytomegalovirus, Epstein-Barr virus, human immunodeficiency virus, and parvovirus B19 were all negative. Thoracic computed tomographic scans or abdominal sonography showed no evidence of an abnormal mass such as thymoma or lymphoma. Bone marrow examination showed reduced cellularity (0-20%) and severe erythroid hypoplasia, whereas thrombopoiesis was in the low normal range and granulopoiesis was normal, findings consistent with PRCA (Fig. 1).

Bottom Line: Anti-erythropoietin antibodies usually cross-react with all kinds of recombinant erythropoietins; therefore, erythropoiesis-stimulating agent (ESA)-induced pure red-cell aplasia (PRCA) is not rescued by different ESAs.Interestingly, anti-erythropoietin antibodies were still detectable, although their concentration was too low for titration.In conclusion, darbepoetin-α can improve ESA-induced PRCA when the anti-erythropoietin antibody titer declines and its neutralizing capacity is lost.

View Article: PubMed Central - PubMed

Affiliation: Divison of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.

ABSTRACT
Anti-erythropoietin antibodies usually cross-react with all kinds of recombinant erythropoietins; therefore, erythropoiesis-stimulating agent (ESA)-induced pure red-cell aplasia (PRCA) is not rescued by different ESAs. Here, we present a case of ESA-induced PRCA in a 36-yr-old woman with chronic kidney disease, whose anemic condition improved following reintroduction of darbepoetin-α. The patient developed progressive, severe anemia after the use of erythropoietin-α. As the anemia did not improve after the administration of either other erythropoietin-α products or erythropoietin-β, all ESAs were discontinued. Oxymetholone therapy failed to improve the transfusion-dependent anemia and a rechallenge with ESAs continuously failed to obtain a sustained response. However, her anemia improved following reintroduction of darbepoetin-α at 3 yr after the initial diagnosis. Interestingly, anti-erythropoietin antibodies were still detectable, although their concentration was too low for titration. In conclusion, darbepoetin-α can improve ESA-induced PRCA when the anti-erythropoietin antibody titer declines and its neutralizing capacity is lost.

Show MeSH
Related in: MedlinePlus