The patient in this vignette is most likely anemic as a result of her end-stage renal disease. Recombinant eryhtropoietin (EPO) is the treatment of choice for this condition, with the most common side effect being a worsening of hypertension, seen in approximately 30% of patients.
EPO is the treatment of choice for normocytic normochromic anemia with Hgb <10g/dL. Other notable side effects of EPO include headaches (15% of patients), Flu-like syndrome (5% of patients), and red cell aplasia (very rare). Hypertension and flu-like syndrome are seen less often with the subcutaneous delivery of EPO compared to intravenous administration. Mechanistically, erythropoietin is produced by the kidney, this production is reduced in renal disease. EPO activates receptors on erythroid progenitors in bone marrow to stimulate production of red blood cells (RBC). Other uses include anemia as a result of certain bone marrow disorders, chemotherapy toxicity, cancer, and HIV.
Brill and Baumgardener discuss normocytic anemia, which has a high prevalence, approaching 44 percent in men older than 85 years of age. Anemia of chronic disease (ACD) is the most common cause of normocytic anemia and may be found in 6 percent of adult hospitalized patients. A basic work-up includes red blood cell distribution width, corrected reticulocyte index and peripheral blood smear. Treatment is directed at correcting the underlying cause of the anemia, but if uncorrectable, recombinant human erythropoietin is a therapeutic option.
Maiese et al discuss potential therapeutic uses of EPO, which has many roles outside of the hematopoietic system. Recent research has unveiled its cytoprotective role in both neuronal and vascular systems, leading to potential applications in cerebral ischemia, myocardial infarction, and chronic congestive heart failure. Additionally, EPO modulates progenitor stem cell development, cellular integrity, and angiogenesis.
Illustration A displays a response of RBC production following EPO administration.
Answer 1: EPO does not have an association with rash.
Answer 2: Because of an increase in red cell volume, patients are at risk of thrombosis, not bleeding.
Answer 4: EPO does not have an association with pruritus, however, this can be seen with ESRD.
Answer 5: EPO does not have an association with fatigue; it may help treat the fatigue seen in anemic patients.
Brill JR, Baumgardner DJ. Normocytic anemia. Am Fam Physician. 2000 Nov 15;62(10):2255-64.
PMID:11126852 (Link to Abstract)
Maiese K, Li F, Chong ZZ. New avenues of exploration for erythropoietin. JAMA. 2005 Jan 5;293(1):90-5.
PMID:15632341 (Link to Abstract)