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Anti-Erythropoietin Antibodies and Pure Red Cell Aplasia

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Anti-Erythropoietin Antibodies and Pure Red Cell Aplasia DISEASE OF THE MONTH J Am Soc Nephrol 15: 398–406, 2004 EBERHARD RITZ, FEATURE EDITOR Anti-Erythropoietin Antibodies and Pure Red Cell Aplasia JEROME ROSSERT,* NICOLE CASADEVALL,† AND KAI-UWE ECKARDT,‡ *Department of Nephrology, Tenon hospital (AP-HP) and Pierre and Marie Curie University, Paris, France; †Department of Hematology, Hôtel Dieu (AP-HP), Paris, France; and ‡Department of Nephrology and Medical Intensive Care, Charité, Campus Virchow Klinikum, Berlin, Germany More than twenty years ago, investigators who immunized unrecognized phenomenon have not been confirmed, and the rabbits against human erythropoietin (EPO) to generate poly- incidence rates of epoetin-induced PRCA seem to have passed clonal antibodies noted that the animals producing antibodies the peak. Nevertheless, clinicians should be aware of signs and against this hormone became progressively anemic (1). Appar- consequences of this complication. Moreover, this issue raises ently human EPO was sufficiently different from rabbit EPO to important safety considerations for the development and ap- be recognized as a foreign protein; however the antibodies proval of future epoetin molecules and biogenerics, in general. were crossreactive with rabbit EPO and neutralized it. At that time the anemia observed in these animals provided indirect Pure Red Cell Aplasia: A Rare Hematological Disease proof that EPO is an essential growth factor for erythropoiesis. PRCA is an isolated disorder of erythropoiesis that leads to Patients have been treated with recombinant human EPO a progressive, severe anemia of sudden onset (11). Due to an (rHuEPO or epoetin) since the late 1980s. Initially, the recom- almost complete cessation of red blood cell (RBC) production 3 binant hormone was only given intravenously. Several years the blood reticulocyte count is very low (Ͻ10,000/mm ). The later the subcutaneous route of application started to become hemoglobin concentration declines at a weekly rate of about 1 increasingly used, which facilitates self-administration and is g/dl, reflecting a decay that corresponds to normal RBC life believed to reduce dose requirements (2–4). In this clinical span. To avoid very severe anemia and maintain an acceptable context, epoetin-induced antibodies remained a very rare com- hemoglobin level, transfusion of about 1 unit of RBC per week plication for many years, and only few case reports have been is required. The bone marrow examination shows almost com- published (5–7). Like in animals immunized against EPO the plete absence of erythroid precursors, but normal platelet and critical issue in patients developing anti-EPO antibodies is that white cell precursors (Figure 1). A bone marrow aspirate is these antibodies do not only abrogate the effect of the recom- usually sufficient to make the diagnosis, but a biopsy may be binant molecule, but also neutralize residual naturally occuring necessary if the bone marrow smear is not optimal, particularly EPO. The resulting anemia is therefore much more severe than if cellularity is abnormal. before the onset of therapy. Since 1998, the number of reported Factors known to be associated with PRCA include lympho- cases with severe, isolated inhibition of erythropoiesis [pure proliferative disorders and viral infections; in particular, those red cell aplasia (PRCA)] due to the development of anti-EPO with parvovirus B19, systemic autoimmune disease and drugs. antibodies has increased dramatically. This concerns almost However, about half of the cases have no identifiable cause exclusively patients with kidney disease receiving subcutane- (Table 1) (12). In many instances, the pathogenesis involves ous treatment with epoetin (8,9). To date, approximately 250 autoimmune mechanisms. Sera from affected patients were suspected or proven cases have been reported worldwide, the found to contain IgG antibodies that suppress in vitro growth of vast majority of those in association with the use of epoetin alfa erythroid progenitors cells. In addition, inhibition of erythroid outside the United States (10). Given that millions of patients proliferation by T cells has also been shown to play a patho- are treated with epoetins, the prevalence of this complication genic role, even in patients with B cell lymphoproliferative remains very low, but the dynamics of the increase in its disorders. Three cases have also been reported of patients incidence have initially raised great concern. Meanwhile, never exposed to epoetin who developed PRCA due to the causes and risk factors have become somewhat clearer. Spec- formation of autoantibodies against EPO (13–15). In the par- ulations that antibodies against epoetin are a frequent and ticular case of parvovirus B19 infection, which is a known complication after kidney transplantation (16), the virus binds to a neutral glycosphingolipid, which is predominantely found Correspondence to Dr. Kai-Uwe Eckardt, Division of Nephrology and Hyper- on erythroid progenitors (blood group P antigen) (17). After tension, University of Erlangen-Nu¨rnberg, Krankenhausstrasse 12, 91054 Er- infection it induces the formation of giant pronormoblasts and langen, Germany. E-mail: [email protected] cell apoptosis. 1046-6673/1502-0398 Journal of the American Society of Nephrology Diagnosis and Clinical Signs of Epoetin-Induced PRCA Copyright © 2004 by the American Society of Nephrology Diagnostic criteria for epoetin-induced PRCA are summa- DOI: 10.1097/01.ASN.0000107561.59698.42 rized in Table 2. Patients developing PRCA due to anti-EPO J Am Soc Nephrol 15: 398–406, 2004 Anti-erythropietin antibodies and pure red cell aplasia 399 Figure 1. Bone marrow smear. (A) normal bone marrow, containing polychromatrophilic erythroblasts (arrowheads). (B) bone marrow of a patient with PRCA Table 1. Most frequent causes of PRCA Figure 2. Schematic representation of a typical case of epoetin- induced PRCA. Red line: hemoglobin levels. Blue bars: ferritin levels. Lymphoproliferative disorders Infections (e.g., parvovirus B19) Systemic autoimmune disease (e.g., systemic lupus) Drugs (e.g., chloramphenicol) Thymoma (in ϳ5% of cases) Idiopathic (in ϳ50% of cases) Table 2. Diagnosis of epoetin-induced PRCA Major features treatment with epoetin for at least several wk weekly drop of hemoglobin of ϳ1 g/dl without transfusions or transfusion need of ϳ1 U per wk to keep hemoglobin levels in an acceptable range reticulocytes Ͻ 10,000/mm3 no major drop of leukocyte and platelet counts Minor features Figure 3. Reticulocyte counts in dialysis patients without PRCA skin or systemic allergic reactions (black dots) and in CKD patients with PRCA (red dots) Confirmational investigations bone marrow aspirate Ͻ normal cellularity and 5% erythroblasts the median reticulocyte count was 3000/mm3 at the time of evidence for block of maturation diagnosis (18). It has even been suggested that reticulocyte serum counts should be regularly monitored during epoetin therapy to presence of anti-erythropoietin antibodies allow early detection of impaired erythropoiesis (19). How- ever, given the low incidence of epoetin-induced PRCA and absence of evidence that earlier detection will enhance out- antibodies have typically been on epoetin therapy for 6 to 18 come, this proposal has not been widely accepted. mo. The hemoglobin level then suddenly starts to decline at the Systematic analysis of cases reveals that when patients de- rate indicated above, despite continued therapy with epoetin at velop PRCA, they also experience a significant drop of platelet the same or even increased doses (8) (Figure 2). The shortest counts. Whether this is related to direct effects of EPO on time interval between start of epoetin therapy and loss of megakaryopoiesis (20,21) or more complex interaction of efficacy observed in a single case was 2 mo and the longest platelet formation with erythroid precursor cells is unknown. In was 90 mo. any case, the decline in platelet counts does not appear to be The reticulocyte count obtained by automatic flow cytom- clinically significant, and in most cases thrombocytes do not etry is of great value in the differential diagnosis of the loss of fall below the normal range. A further striking phenomenon efficacy of epoetin. Although great variation of this parameter that has been regularly observed in CKD patients with PRCA is seen in patients with chronic kidney disease (CKD) receiving is a marked and rapid increase in transferrin saturation and epoetin (Figure 3), values above 20,000/mm3 seem to exclude ferritin levels (Figure 2). In a series of 33 patients, median the diagnosis of PRCA. In a series of 45 patients with PRCA, transferrin saturation was 80% at the time of diagnosis (18). 400 Journal of the American Society of Nephrology J Am Soc Nephrol 15: 398–406, 2004 This also reflects the cessation of erythropoiesis and, thus, the interruption of iron utilization. In some instances, skin reac- tions have been observed at the sites of recent or former subcutaneous injections, which points to an important role of local immune reactions in the pathogenesis of anti-EPO anti- body formation (22). Definite diagnosis of epoetin-induced PRCA requires two confirmatory investigations: a bone marrow examination and the demonstration of anti-EPO antibodies in the patient’s se- rum. Both investigations should be performed when the diag- nosis is suspected. Cases in which the results of either the antibody test or the bone marrow examination are not available or inconclusive should, however, not be excluded from epide- miologic surveys and need to be reported to health authorities. In fact, databases maintained by manufacturers of epoetins contain a significant percentage of cases for which the diag- nostic work-up and evidence for epoetin-induced PRCA is incomplete. A possible case definition that takes into account the different levels of certainty in the diagnosis is proposed in Table 3. Assays for Anti-EPO Antibodies Since epoetin-induced PRCA is due to the production of neutralizing anti-EPO antibodies, the identification of these antibodies in serum samples is the key to the diagnosis. Four different types of tests have been developed that have different advantages and limitations.
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