Update on reintroduction of epoetin in a patient with pure red call aplasia.

Sir, A recent review of recombinant human erythropoietin (rHuEPO)-associated pure red cell aplasia (PRCA) cautioned re-challenge with the same or alternative rHuEPO products in the face of continued anaemia in patients with end-stage renal failure [1]. The mainstay of treatment should involve withdrawal of epoetin therapy, immunosuppression and supportive correction of anaemia with blood transfusion. Whilst epoetin re-challenge can be attempted, caution is advised in the face of reported relapse, even with an alternative rHuEPO [2]. Our unit initially reported the case of an 81-year-old man who developed PRCA with positive anti-EPO antibodies whilst on subcutaneous epoetin-alpha in May 2002 [3]. His epoetin was discontinued, and following the 4-month treatment with cyclosporin his anti-EPO antibodies became negative. He became transfusion dependent and after a further 9 months the decision was made to restart him on alternative EPO therapy because of persistent anaemia. He was commenced on darbepoetin and had a successful response to therapy. He remained on cyclosporin throughout this time although subsequent withdrawal had been discussed. The patient chose to remain on cyclosporin as he had suffered no adverse effects. This was one of the first reports of the successful reintroduction of rHuEPO in a patient with PRCA. He remained well and transfusion independent with a haemoglobin level between 10.5 and 11.5 g/dL for 4 years. He subsequently died, aged 84, following complications after a fractured neck of femur. To date there are no reports of any patients having tolerated reintroduction of epoetin following PRCA for a longer duration. This case illustrates the potential benefits, and safety, of long-term immunosuppressant therapy supporting the reintroduction of rHuEPO following PRCA.