title: Triple immunosuppressive therapy can accelerate the recovery of antibody-mediated pure red cell aplasia and allow successful concurrent resumption of erythropoietin.
abstract: Antibody (Ab)-mediated pure red cell aplasia (PRCA) is a rare hematologic disorder. For the first time here, the authors report the use of combination therapy which consists of mycophenolate mofetil 500-1000 mg/day, intravenous cyclophosphamide 600 mg monthly and monthly intravenous methylprednisolone 1 gm/day for 2 days followed by oral prednisolone 10 mg/day. A 62-year-old woman developed Ab-mediated PRCA after using subcutaneous erythropoietin-beta 3000 U weekly for 14 months at the predialysis stage. Ab-mediated PRCA was diagnosed based on (1) the transfusion need of more than 1 unit/wk to keep hemoglobin level stable, (2) corrected reticulocyte count 0.36% and (3) < 5% erythroblasts with normal myeloid cells and megakaryocytes in bone marrow biopsy. Serum assay confirmed the anti-erythropoietin antibody of 230 ng/mL. The patient recovered from PRCA after the triple immunosuppressive therapy for 3 months. The rapid recovery occurred despite the fact that the patient was receiving intravenous erythropoietin-alpha while having the antibody in the serum. The present case describes the acceleration of the recovery and successful resumption of erythropoietin concurrently despite the positive serum anti-erythropoietin antibody.
authors.affiliation: Division of Nephrology, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand. prajej@gmail.com
authors.forename: Prajej
authors.initials: P
authors.lastname: Ruangkanchanasetr
authors.forename: Tanomsri
authors.initials: T
authors.lastname: Srichaikul
authors.forename: Thanom
authors.initials: T
authors.lastname: Supaporn
mesh_terms: D003520:Cyclophosphamide / Q000008:administration & dosage; D004359:Drug Therapy, Combination; D004797:Enzyme-Linked Immunosorbent Assay; D017707:Erythrocyte Transfusion; D004921:Erythropoietin / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D007165:Immunosuppression Therapy / Q000379:methods*; D007676:Kidney Failure, Chronic / Q000188:drug therapy*; D008875:Middle Aged; D009173:Mycophenolic Acid / Q000008:administration & dosage / Q000031:analogs & derivatives; D011239:Prednisolone / Q000008:administration & dosage; D012010:Red-Cell Aplasia, Pure / Q000175:diagnosis / Q000188:drug therapy* / Q000276:immunology*
chemical_list: D004921:Erythropoietin; D003520:Cyclophosphamide; D011239:Prednisolone; D009173:Mycophenolic Acid