Anti-Erythropoietin Antibodies and ESA Hyporesponsiveness in Hemodialysis Patients: A Review Article

Abstract

Background: Anemia is a common complication in chronic kidney disease and is associated with reduced quality of life, worse renal survival, increased morbidity and mortality, and higher healthcare costs. The mechanisms involved in CKD-related anemia are diverse and complex, including decreased endogenous erythropoietin production, absolute or functional iron deficiency, inflammation, increased hepcidin levels, shortened red blood cell survival, and impaired bone marrow response. Erythropoiesis-stimulating agents and iron supplementation remain the main therapeutic approaches, but some patients show poor response despite treatment. This review aims to discuss anemia of chronic kidney disease with special focus on erythropoiesis-stimulating agent hyporesponsiveness, its major causes, clinical consequences, and the role of anti-erythropoietin antibodies as a rare but clinically significant immune-mediated mechanism of ESA resistance.

Conclusion: ESA hyporesponsiveness is a multifactorial problem in patients with chronic kidney disease and hemodialysis. Iron deficiency, infection, inflammation, inadequate dialysis, hyperparathyroidism, malnutrition, medications, and pure red cell aplasia may all contribute to poor response. Anti-erythropoietin antibodies represent an uncommon but important cause of severe ESA resistance, particularly when associated with pure red cell aplasia. Early recognition and systematic evaluation of ESA hyporesponsiveness are essential to optimize anemia management and reduce transfusion requirements.