Successful Rechallenge with Darbepoetin Following Immunosuppressive Therapy in a Dialysis Patient with Erythropoietin-Induced Pure Red Cell Aplasia

Abstract

Patients with erythropoiesis-stimulating agent (ESA)-induced pure red cell aplasia (PRCA) should not routinely be switched to an alternative ESA or to darbepoetin-α because anti-erythropoietin (anti-EPO) antibodies cross-react with all kinds of recombinant ESAs. We present a case of ESA-induced PRCA in a 69-year-old man on hemodialysis whose anemia improved with reintroduction of darbepoetin-α following immunosuppressive therapy. The patient developed severe anemia after 15 months of subcutaneous administration of erythropoietin-α. After the diagnosis of PRCA, erythropoietin-α was discontinued and immunosuppressive therapy with a combination of prednisolone and oral cyclophosphamide was initiated. After 4 months of immunosuppressive therapy, the anti-EPO antibody titer was markedly decreased; however, esophageal candidiasis developed. Additional therapy with cyclosporine alone instead of prednisone and cyclophosphamide was performed, and anti-EPO antibody was subsequently not detected. Darbepoetin-α was then reintroduced, and the patient’s anemia improved without red cell transfusion. In conclusion, ESA-induced PRCA was successfully treated with reintroduction of darbepoetin-α following immunosuppressive therapy. (Korean J Med 2013;84:742-746)