CLINICAL IMMUNOSUPPRESSION - KIDNEY EARLY

K. Janda¹, W. Sulowicz², A. Krasniak¹, M. Krzanowski¹, E. Chowaniec¹, P. Jaskowski¹, I. Kaczmarczyk¹, W. Dzugan¹, K. Galazka³, K. Dziewanowski^4
1Of Nephrology, Jagiellonian University, Krakow/POLAND, ²Dept. Of Nephrology, Jagiellonian University, Krakow/POLAND, ³Of Pathomorphology, Jagiellonian University, Krakow/POLAND, ⁴Of Nephrology, Hospital, Szczecin/POLAND

Body: Pure red cell aplasia (PRCA) is a rare, serious, potentially life-threatening complication secondary to anti-EPO antibodies. Case presentation A 30 year old male with ESRD started maintenance hemodialysis on May 28, 2007 and erythropoietin beta (NeoRecormon) subcutaneously, 6000 IU once weekly (prefilled syringes). On July 2007, he was transferred to another Dialysis Center where he continued NeoRecormon sc treatment (Multidose) with good response (mean Hb concentration equaled 10.9 g/dl a mean dosage of EPO of 3200 IU/weekly. Mean Hb concentration significantly decreased in March 2008 to a value of 7.6 g/dl. Even though EPO dosage was increased to 9000 IU/week), drug route changed from sc to iv and transfusion of 3 units of blood in April was performed, Hb concentration continued to decrease to a value of 5.5 g/dl. From April to August, 2008 the patient became transfusion dependant- a mean of 3 units of blood/month. The patient also developed a skin rash in the location of subcutaneous EPO administration. The patient was admitted to the Department of Nephrology where PRCA was diagnosed based on bone marrow biopsy (erythroid hypoplasia) as well as appearance of anti-EPO antibodies (MicroCoat Biotechnologie GmbH); first result- titer of 1492 ng/ml. In August, 2008 after the diagnosis was proved, CsA was introduced into treatment at a starting dose of 5 mg/kg/day (Neoral 2 x 150mg) and MP 0.5 mg/kg/daily (Metypred 1x32mg). Dosage of CsA was modified during treatment depending on blood concentration. After 3 months of treatment, anti-EPO antibody titer began to decrease to a value of 115.5 ng/ml and Hb concentration stabilized at a level fluctuating from 9.3 to 10.1 g/dl. The last blood transfusion was in October 2008. Reticulocytes significantly increased from 0.3%o to 27.7%o. Control bone biopsy performed 3 months after initiation of immunosuppression showed complete renewal of the erythroid line. In April, 2009 the patient underwent cadaver kidney transplantation (Tacrolimus at a dose of 0.1 mg/kg/body weight and steroid therapy- Solu-Medrol 500mg i.v. with consequent transition to oral route). Level of anti-EPO antibodies before surgery was 24.9 ng/ml.). The transplanted kidney immediately began functioning, patients was discharge after 17 days with Hb 10.2 g/dl, creatinine 1.2 mg/dl (GFR-75.75 ml/min/1.73 m²) and triple immunosuppressive therapy TAC, MMF and steroids. After long-term observation, 10 months post Tx- Hb concentration stabilized (mean level - 12 g/dl). The patient did not require blood transfusions, neither hospitalization, nor were any other complications noted. Level of anti-EPO antibodies after 2 months post Tx equaled 1.9 ng/ml. Conclusions: Multiple immunosuppression therapy consisting of calcineurin inhibitors with steroids may be recommended in the treatment of PRCA induced by anti-EPO antibodies as effective treatment; however renal transplant is the treatment of choice along with immunosuppression in treatment of PRCA induced by anti-EPO antibodies.

Disclosure: All authors have declared no conflicts of interest.