Association of Erythropoietin-Stimulating Agent Responsiveness with Mortality in Hemodialysis and Peritoneal Dialysis Patients

Abstract

Erythropoiesis-stimulating agent (ESA) responsiveness has been reported to be associated with increased mortality in hemodialysis (HD) patients. ESA requirement to obtain the same hemoglobin (Hb) level is different between HD and peritoneal dialysis (PD) patients. In this study, we investigated the impact of ESA responsiveness on mortality between both HD and PD patients. Prevalent HD and PD patients were selected from the Clinical Research Center registry for end-stage renal disease, a prospective cohort study in Korea. ESA responsiveness was estimated using an erythropoietin resistant index (ERI) (U/kg/week/g/dL). Patients were divided into three groups by tertiles of ERI. ESA responsiveness was also assessed based on a combination of ESA dosage and hemoglobin (Hb) levels. The primary outcome was all-cause mortality. A total of 1,594 HD and 876 PD patients were included. The median ESA dose and ERI were lower in PD patients compared with HD patients (ESA dose: 4000 U/week vs 6000 U/week, respectively. P<0.001, ERI: 7.0 vs 10.4 U/kg/week/g/dl, respectively. P<0.001). The median follow-up period was 40 months. In HD patients, the highest ERI tertile was significantly associated with higher risk for all-cause mortality (HR 1.96, 95% CI, 1.07 to 3.59, P = 0.029). HD patients with high-dose ESA and low Hb levels (ESA hypo-responsiveness) had a significantly higher risk of all-cause mortality (HR 2.24, 95% CI, 1.16 to 4.31, P = 0.016). In PD patients, there was no significant difference in all-cause mortality among the ERI groups (P = 0.247, log-rank test). ESA hypo-responsiveness was not associated with all-cause mortality (HR = 1.75, 95% CI, 0.58 to 5.28, P = 0.319). Our data showed that ESA hypo-responsiveness was associated with an increased risk of all-cause mortality in HD patients. However, in PD patients, ESA hypo-responsiveness was not related to all-cause mortality. These finding suggest the different prognostic value of ESA responsiveness between HD and PD patients.

Residual renal function in chronic dialysis is not associated with reduced erythropoietin-stimulating agent dose requirements: a cross-sectional study

“…We found a strong association between higher ERI and laboratory evidence of systemic inflammation. Others have reported similar findings [ 5 , 17 ]. None of our patients were iron deficient or had an obvious infection.…”

“…Another study that was conducted in PD patients reported no influence of RRF on ERI [ 17 ]. A recent, large observational study reported that ERI was higher for patients on HD as compared to those on PD [ 5 ]. It is unclear whether patients included were on stable ESA doses and what the effect RRF may have had.…”

“…We found no association between ERI and dialysis modality, RAS blocker use, the underlying primary renal disease or hyperparathyroidism. A recent meta-analysis also reported no difference relative to dialysis modality [ 3 ], although some individual studies have reported differences [ 4 , 5 ]. There was a trend toward less RRF in those with RAS blocker use.…”

“…A recent meta-analysis found no difference in Hb concentrations between haemodialysis (HD) and peritoneal dialysis (PD) patients [ 3 ]; however, treatment response to ESA may vary depending on dialysis modality. It has been reported that PD patients tend to have lower ESA dose requirements than their HD counterparts [ 4 , 5 ]. Possible explanations for this include less frequent phlebotomy, subcutaneous administration of ESA that is associated with up to a third saving in dose and finally the preservation of residual renal function (RRF) [ 6 ].…”

Aspectos epidemiológicos de pacientes com doença renal crônica em programa de diálise peritoneal: levantamento de 22 anos

“…Esse dado é semelhante em vários estudos (BAE et al, 2015;GONÇALVES et al, 2013;OLIVEIRA et al, 2014;SANABRIA et al, 2015). Ao analisarmos a média Ainda Bevilacqua et al (1995) descreveu dados referentes ao tempo de acompanhamento inferior ao deste estudo como também, Oliveira et al (2016) no qual o tempo de acompanhamento foi de 1,5 anos de seguimento.…”