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Ovid: Oxford Handbook of Dialysis

Editors: Levy, Jeremy; Morgan, Julie; Brown, Edwina Title: Oxford Handbook of Dialysis, 2nd Edition Copyright ©2004 Oxford University Press > Table of Contents > Part 8 – Complications of ESRD: anaemia > Erythropoietin: side-effects Erythropoietin: side-effects

  • Hypertension is the most common complication (20–50% patients):
    • associated with rate of rise in Hb, absolute level of Hb achieved, vasoconstriction induced by treatment, arterial remodelling and enhanced responsiveness to noradrenaline;
    • hypertensive encephalopathy was seen during the early days of EPO and was associated with a rapid rise in Hb and BP;
    • severe hypertension is not seen with slow controlled rise of Hb.
  • Hypertension should be managed by fluid removal and appropriate drug treatment.
  • EPO and darbepoietin should not be withheld unless evidence of accelerated hypertension.
  • Pain at injection site occurs in a few patients using darbepoietin SC; it is much less common with EPO-β.

Pure red cell aplasia This is rare but devastating.

  • Caused by formation of antibodies to EPO.
  • Very rare and occurred predominantly in patients treated with Eprex (European brand of EPO-α).
  • Thought to be due to change in the immunogenicity of the EPO molecule brought about by removing human albumin from solvent (because of risk of prion infection).
  • Mostly occurred with SC route of administration, because of increased immunogenicity of proteins when injected SC.
  • Diagnosis should be suspected if Hb falls despite increasing dose of EPO—and reticulocyte count is <1% (or <10×109/l), with normal platelet and white cell counts.
  • Diagnosis confirmed by finding anti-EPO antibodies in serum, and bone marrow feature of PRCA.
  • Various immunosuppression strategies have been used as treatment with some success; Hb will rise, but often reintroduction of EPO (any brand) will re-stimulate production of antibodies. Kidney transplantation can be curative.
  • New cases of PRCA now very rare since Eprex only used intravenously.
  • No cases have occurred with Aranesp.

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