Iron deficiency anemia associated with extracorporeal photopheresis: A retrospective analysis

Abstract

Background Extracorporeal photopheresis (ECP) is associated with few adverse effects. We have anecdotally noted patients treated with long‐term ECP develop iron deficiency anemia (IDA). Methods We performed a retrospective chart review of adult patients who received ECP for any indication at Mayo Clinic Rochester and Mayo Clinic Arizona. The primary objective was to describe the cumulative incidence of IDA at 1 year of ECP therapy. Results A total of 123 patients were eligible for analysis. Graft‐vs‐host disease was the most common indication for ECP (n = 76, 61.8%). At 1 year of ECP therapy, the cumulative incidence of IDA was 24.1% (95% CI, 14.2%‐32.9%). At 5 years, the cumulative incidence of IDA was 68.3% (95% CI, 38%‐83.8%). Risk factors for the development of IDA included: cumulative number of ECP sessions (HR 1.34, 95% CI, 1.05‐1.73 per 10 additional sessions, P = .022), an indication for ECP of solid organ transplant rejection (compared to cutaneous T‐cell lymphoma, HR 5.46, 95% CI, 2.06‐14.49, P < .001), and proton pump inhibitor use at baseline (HR 2.15, 95% CI, 1.1‐4.21, P = .03). Iron supplementation was initiated in 29 of 37 evaluable patients who developed IDA, with a cumulative incidence of supplementation in 77.2% patients within 3 months of recognition of IDA (95% CI, 55.8%‐88.3%). Hemoglobin normalized in 50.1% of patients started on iron supplementation for IDA within 7 months (95% CI, 25.2%‐66.7%). Conclusions Iron deficiency anemia is common in patients receiving long‐term ECP and occurs throughout ECP therapy. IDA resolved with iron supplementation in half of patients.

Development of iron deficiency anemia in patients undergoing extracorporeal photopheresis: Comparison of the UVAR and CELLEX instruments

“…Overall, 77.2% of these patients required iron supplementation. (Table 3 provides a summary of results from our study and those of Sanford et al and Kuhn et al) 11 . Interestingly, the prior studies noted a positive association with number of treatments and the diagnosis of GVHD and BOS.…”

“…Similar to previous studies, a relationship to patient age, ethnicity, ECP indication/disease category, starting hemoglobin, hemoglobin nadir, or duration of ECP treatment could not be definitively established 8,11 . In the study by Sanford, et al, chronic ECP led to IDA in 80% of patients studied, which was attributed to blood loss from ECP equipment secondary to failure to fully return blood volume to the patient's circulation.…”

“…Limitations of the study include the retrospective nature in which not all patients had regular follow‐up or lacked complete laboratory profiles to fully characterize the anemia. Moreover, the inclusion of GVHD patients with complex medical histories has the ability to confound the study, as these patients in particular are prone to develop complications which may mimic or mask true IDA 11 . Indeed, the most severe anemia of our cohort was overwhelmingly represented in this subpopulation of patients, especially in patients receiving CELLEX procedures.…”

Impact of extracorporeal photopheresis on blood and coagulation parameters

“…However, the correlation of decreases in hemoglobin, MCV, and hematocrit indicate that iron deficiency was likely the cause of anemia in most cases. [8][9][10] In addition, particularly changes in lymphocyte and leucocyte counts could also be explained, at least in part, by concomitant immunosuppressive therapies (e.g., immunosuppressants) and/or exacerbated by the underlying disease (e.g., GvHD) without any influence by ECP. [8][9][10] Nevertheless, the acute changes observed 24 h after the first cycle of ECP indicate that the procedure may have a direct impact on blood parameters.…”

“…[3][4][5][6][7] Even though ECP is generally well tolerated, there is a lack of studies systematically investigating laboratorybased adverse events (AEs) under ECP. [7][8][9][10][11][12] Based on these considerations, we chose a reasonable sample size of ECP patients to evaluate acute and chronic changes in peripheral blood parameters including coagulation.…”