Possible complications of erythropoietin therapy in patients with chronic renal failure

• Published in: Medicinski pregled Vol. 57; no. 5-6; pp. 254 - 257
• Main Author: Pljesa, Steva
• Format: Journal Article
• Language: Serbian; English
• Published: Serbia 01.05.2004
• Subjects: Anemia - etiology; Anemia - therapy; Erythropoietin - adverse effects; Humans; Kidney Failure, Chronic - complications; Kidney Failure, Chronic - therapy; Recombinant Proteins; Red-Cell Aplasia, Pure - chemically induced; Red-Cell Aplasia, Pure - diagnosis; Red-Cell Aplasia, Pure - therapy; Renal Dialysis
• DOI: 10.2298/MPNS0406254P
• ISSN: 0025-8105

There have been many publications in the past 20 years about positive effects of human recombinant erythropoietin, which is used in treatment of anemia, especially in patients on dialysis. The most important complications in patients treated with erythropoietin include: hypertensive reactions; thrombosis of AV fistula in patients on hemodialysis and appearance of severe anemia as a part of Pure Red Cell Aplasia (PRCA). The first two complications were managed quite easily with adequate erythropoietin dosage, and slower establishment of normal hemoglobin kevel, hematocrit level and red blood cell count, (our "target" Hb varied between 100 and 110 g/dl). PURE RED CELL APLASIA (PRCA): Pure Red Cell Aplasia is a progressive, marked anemia with sudden appearance of significant loss or complete absence of erythrocyte precursor cells in normal bone marrow. In patients with end stage renal disease treated with erythropoietin PRCA appears in acute form as a consequence of production of neutralizing antibodies to erythropoietin. Time period between the beginning of erythropoietin therapy and appearance of PRCA is from 3 weeks to approximately 9 months. PRCA is characterized by sudden appearance of anemia in patients who had a satisfactory response to erythropoietin therapy till that moment. In PRCA, anemia is normocytic, normochromic with normal survival of red blood cells, without deficit in components such as iron, folic acid or vitamin B12, low reticulocyte count, decrease in Hg and normal platelet count. Diagnosis is based on clinical data (marked anemia), bone marrow biopsy, which shows a lower number of precursor red blood cells and presence of antibodies against erythropoietin. Before PRCA is diagnosed, all other causes for erythropoietin resistance must be excluded. Therapy of PRCA is based on cessation of erythropoietin therapy (all kinds), and correction of anemia with blood transfusions. PRCA is very rare and occurs in less than 1:10.000 patient-years in patients treated with erythropoietin, not lethal by itself and generally reversible. Till December 31, 2002. PRCA has been diagnosed in 142 patients world wide. In Serbia and Montenegro till this moment there hasn't been a single case of this syndrome. Continuous follow-up of reticulocyte count is the first step. Although this is a very rare disease, most of European Societies of Nephrology made protocols that recommend only intravenous application of -epoetin. Considering this new situation, Nephrology Society of Serbia and Montenegro recommends that -epoetin should be given to patients on hemodialysis only intravenously, while subcutaneous application of -epoetin is recommended in patients before beginning the dialysis treatment and in patients on hemodialysis, or who had undergone kidney transplantation.