Antibodies to recombinant human erythropoietin causing pure red cell aplasia

Recombinant human erythropoietin (rHuEPO) is used extensively in anemic patients on dialysis and other patients and is regarded as very safe and effective in the management of anemia in these patients. To date, there is no report on the development of antibodies to rHuEPO in the patients treated with this drug. We report here a patient who developed antibodies to rHuEPO and as a result developed pure red cell aplasia. A 63-year-old black male with end-stage renal disease secondary to hypertension was placed on chronic dialytic therapy and tolerated rHuEPO treatment well for two years. A rapidly progressive anemia was then noted which was unresponsive to maximal doses of rHuEPO and the patient soon became transfusion-dependent. Bone marrow examination revealed paucity of red cell precursors. A detailed search for the cause of this pure red cell aplasia was unrevealing. Serological tests for Parvovirus B19 infection were negative. Antibodies for rHuEPO were tested by radioimmuno-precipitation assay and were found positive. In the course of several months, the antibody titer declined spontaneously to negligible levels with simultaneous improvement in the anemia and reappearance of red cell precursors in the bone marrow. This is the first patient to be reported who formed antibodies to rHuEPO and as a consequence developed pure red cell aplasia. Thus we conclude that although very rare, antibody production to rHuEPO should be considered in evaluating patients with EPO-resistant anemia with no obvious etiology.