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Pure red cell aplasia due to anti-erythropoietin antibodies

Jeffrey S Berns, MD
Section Editors
Steve J Schwab, MD
Stanley L Schrier, MD
Deputy Editor
Alice M Sheridan, MD


Acquired pure red cell aplasia (PRCA) is a rare condition of profound anemia characterized by a very low reticulocyte count and the virtual absence of erythroid precursors in the bone marrow. All other cell lines are present and seem quantitatively and morphologically normal. Many cases of acquired PRCA are idiopathic. In others, underlying conditions, such as thymoma, myelodysplastic syndromes, lymphoma, leukemia, systemic autoimmune disorders, and viral infection (ie, parvovirus B19), or treatment with drugs, such as phenytoin or chloramphenicol, are identified [1]. (See "Acquired pure red cell aplasia in the adult".)

PRCA has also been described in patients treated with epoetin (EPO), resulting from the induction of neutralizing antibodies directed against the EPO molecule [2]. Most reported cases have been in patients receiving EPO for chronic kidney disease (CKD)-related anemia.

PRCA due to anti-EPO antibodies in patients with CKD will be reviewed here. A discussion of other causes of acquired PRCA is presented separately. (See "Acquired pure red cell aplasia in the adult".)


Most cases of non-erythropoietin (EPO)-related PRCA are mediated by immunoglobulin G (IgG) autoantibodies or cytotoxic T lymphocytes directed against erythroid precursor or progenitor cells [1,3]. Inhibition of erythropoiesis occurs primarily between the colony forming unit–erythroid (CFU-E) and proerythroblast stages. The proerythroblast is the first morphologically identifiable erythroid precursor in normal marrow and is virtually absent in the marrow of patients with PRCA. (See "Acquired pure red cell aplasia in the adult".)

PRCA due to autoantibodies against endogenous EPO is rare in patients who have never been treated with erythropoiesis-stimulating agents (ESAs) [4-6]. The serum of patients with EPO-related PRCA inhibits the growth of erythroid progenitor cells in bone marrow cultures [2]. Neutralizing IgG antibodies to the protein component of exogenous recombinant EPO are found that crossreact with endogenous EPO.

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Literature review current through: Nov 2017. | This topic last updated: Aug 07, 2017.
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