Erythropoietin (Epo or EPO) is a protein hormone produced by the kidneys in response to hypoxia, and is also a prescription drug used for treating anemia. It is essential for normal development and maturation of red blood cells (RBC), and abnormally high levels of either the endogenous or drug form can lead to dangerously high hematocrit values.
Carnot and DeFlandre [1] made initial observations in rabbits that suggested the existence of a factor in peripheral blood that could stimulate production of reticulocytes. Their experiment involved bleeding a rabbit to induce accelerated RBC production, they then transferred some of the plasma to a recipient animal. The key observation of increased reticulocytes in the recipient animal prompted the search for a substance, which they named hemopoietin, that regulated the rate of RBC production.
A major breakthrough came in 1977, when small amounts of erythropoietin were purified from the urine of patients with aplastic anemia.[2] Amino acid sequence data from this protein were used in subsequent efforts to clone the gene for erythropoietin in 1983.[3] The gene was then inserted into a suitable mammalian cell line, Chinese hamster ovary cells, allowing large-scale manufactureof the protein as a commercial product. It was approved for use in 1991. About $10B was spent worldwide in 2006 for treatment of patients with rHuEpo, with about $2B for the cost of treating Medicare patients on renal dialysis.[4]
Erythropoietin exists in several forms and goes by several names. The endogenous form is also referred to as 'epoetin alfa' and sometimes spelled as 'erythropoetin'; it can be abbreviated to Epo, EPO or EP. Various synthetic forms of recombinant (r) human (h) Epo are available, collectively referred to as rHuEpo or rhEpo. These include:
Epo is a glycoprotein with a molecular mass of 30.4 kD. Its structure includes a 165-amino acid backbone with three N-linked carbohydrates attached to asparagines at amino acid positions 24, 38, and 83 and one O-linked carbohydrate attached to Ser126 .[6] The carbohydrate residues allow for many possible isoforms and contribute to the stability of the hormone in vivo. Darbepoetin (see above) was created through site-directed mutation of two amino acid residues, allowing for two additional N-linked carbohydrate chains.
Epo is produced by peritubular cells in the adult kidney, and in hepatocytes in the fetus. In adults, a small amount is also produced by the liver. The rate of Epo synthesis and secretion depends on local oxygen concentrations; hypoxia is the main stimulus for Epo production. The serum concentration of Epo in adults is normally 4-27 mU/mL. In adults with non-renal anemias, the serum concentration tends to increase with the severity of the anemia.
Epo's activities depend on successful interaction with its receptor, which is prominent on the surface of developing RBC in the bone marrow. Epo signaling acts to prevent or retard apoptosis, i.e., it acts as a survival factor for developing cells. The increase in RBC mass brought about by Epo stimulation of the bone marrow completes a self-regulating feedback loop, since (other things being equal), the increased RBC mass would lessen the hypoxia experienced by the kidney and thus, lessen Epo production.
Testing serum erythropoetin may help the evaluation of erythocytosis.
Erythropoietin may increase hypertension patients with chronic kidney disease.[7] The use of when the hemoglobin is less than 9 g per deciliter may increase the risk of stroke according to a randomized controlled trial.[8]
Use of erythropoiesis-stimulating agents for anemia related to cancer may increase mortality.[9]
Although the use of erythropoietin has been studied in critically ill patients, erythropoietin has not been shown to be effectice in this setting. In a randomized controlled trial, erythropoietin insignificantly reduced mortality among critically ill patients.[10] The editorial accompanying the trial concluded that other commonly accepted interventions (such as primary prevention of coronary artery disease in patients with hypertriglyceridemia) were more useful for treatment.
A meta-analysis that included this trial does "not recommend the routine use of erythropoietin-receptor agonists in critically ill patients".[11]
Erythropoietin is sometimes used by nonanemic athletes to increase their body's oxygen-carrying capacity and thus gain an unfair advantage in competition. Besides the risk of disqualification for cheating, athletes who participate in this illicit use of erythropoietin risk the complications of abnormally high red blood cell concentrations, which include abnormal blood clotting. Detection of illicit erythropoietin use is challenging because endogenous and exogenous (pharmaceutical) erythropoietin are almost identical. Several tests rely on altered patterns of glycosylation of erythropoietin shed in the urine. Other detection methods rely on altered parameters of red blood cell production such as hematocrit, reticulocyte hematocrit, the proportion of abnormally large red blood cell, the serum erythropoietin level, and the soluble transferrin receptor concentration.[12]
Erythropoietin's activity in the bone marrow to increase red cell production hinges on its ability to inhibit apoptosis. Experimental treatment of diseases in which apoptosis is prominent have yielded promising initial results. For example, erythropoietin has been proposed as being both safe and beneficial in acute stroke.[13]
Erythropoietin is associated with an increased risk of adverse cardiovascular complications in patients with kidney disease if it is used to increase hemoglobin levels above 13.0 g/dl.[14]
The FDA released an advisory[15] on March 9, 2007, and a clinical alert[16] on February 16, 2007, about the use of erythropoeisis-stimulating agents. The advisory noted these drugs had a "higher chance of serious and life-threatening side effects and/or death...and had a higher rate of deep venous thrombosis".
Erythropoietin may increase blood pressure.[7]