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PRCA Management ESA Alternatives — ESENeph MCQ

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HardChronic Kidney DiseasePRCA Management ESA AlternativesESENeph

A 50-year-old man with CKD G4 develops worsening anaemia on Darbepoetin. His reticulocyte count is very low (10 x 10^9/L). Bone marrow biopsy shows absent erythroid precursors with normal myeloid and megakaryocyte lineages. Anti-EPO antibodies are positive. He was previously on Epoetin alfa. What is the specific management?

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Correct answer: D — Stop all ESAs immediately (cross-reactive antibodies neutralise all ESAs); consider Peginesatide (if available) or HIF-PHI (Roxadustat) as alternative erythropoiesis stimulators; immunosuppression may be considered

ESA-induced pure red cell aplasia (PRCA) is caused by anti-EPO antibodies that cross-react between all ESA formulations. ALL ESAs must be stopped immediately. Transfusions provide supportive bridge therapy. Treatment options include: immunosuppression (Ciclosporin, Mycophenolate) to suppress antibody production; Peginesatide (a peptide EPO-receptor agonist structurally dissimilar to EPO, though availability is limited); or HIF-PHIs (Roxadustat, Daprodustat – stimulate endogenous EPO production via a different mechanism). Some patients respond to immunosuppression and can eventually restart ESAs cautiously.

Reference: KDIGO 2025 – Anemia in CKD; Casadevall et al 2002 – PRCA Management