Use of Erythropoietin Before the Initiation of Dialysis and Its Impact on Mortality

Fink, Jeffrey C.; Blahut, Steven A.; Reddy, Manoj; Light, Paul D.

doi:10.1053/ajkd.2001.21305

Cited by 138 publications

(71 citation statements)

References 12 publications

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“…This finding is in line with previous observational studies in adults and children. [1][2][3] By contrast, interventional trials in adults undergoing hemodialysis and adult diabetic patients with CKD demonstrated an increased risk of cardiovascular events and mortality associated with high hemoglobin targets. [4][5][6] The mechanisms underlying adverse outcomes with full anemia correction may include an increased risk of thrombus formation by hemoconcentration, as well as off-target effects of the high ESA doses required to fully normalize Hb levels.…”

Section: Discussionmentioning

confidence: 99%

“…Whereas correction of hemoglobin (Hb) levels to near-normal has previously been recommended on the basis of association studies linking more severe anemia to morbidity and mortality with dialysis, [1][2][3] interventional clinical trials consistently demonstrate that near-normalization of Hb increases the risk of vascular events and mortality in adults receiving maintenance hemodialysis and in those with CKD who are not undergoing dialysis. [4][5][6] This has prompted ongoing reevaluation and revisions of treatment targets in patients exposed to erythropoiesisstimulating agents (ESAs).…”

mentioning

confidence: 99%

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Management of Anemia in Children Receiving Chronic Peritoneal Dialysis

Borzych-Dużałka

Bilginer

et al. 2013

Journal of the American Society of Nephrology

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Little information exists regarding the efficacy, modifiers, and outcomes of anemia management in children with CKD or ESRD. We assessed practices, effectors, and outcomes of anemia management in 1394 pediatric patients undergoing peritoneal dialysis (PD) who were prospectively followed in 30 countries. We noted that 25% of patients had hemoglobin levels below target (,10 g/dl or ,9.5 g/dl in children older or younger than 2 years, respectively), with significant regional variation; levels were highest in North America and Europe and lowest in Asia and Turkey. Low hemoglobin levels were associated with low urine output, low serum albumin, high parathyroid hormone, high ferritin, and the use of bioincompatible PD fluid. Erythropoiesis-stimulating agents (ESAs) were prescribed to 92% of patients, and neither the type of ESA nor the dosing interval appeared to affect efficacy. The weekly ESA dose inversely correlated with age when scaled to weight but did not correlate with age when normalized to body surface area. ESA sensitivity was positively associated with residual diuresis and serum albumin and inversely associated with serum parathyroid hormone and ferritin. The prevalence of hypertension and left ventricular hypertrophy increased with the degree of anemia. Patient survival was positively associated with achieved hemoglobin and serum albumin and was inversely associated with ESA dose. In conclusion, control of anemia in children receiving long-term PD varies by region. ESA requirements are independent of age when dose is scaled to body surface area, and ESA resistance is associated with inflammation, fluid retention, and hyperparathyroidism. Anemia and high ESA dose requirements independently predict mortality.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Management of Anemia in Children Receiving Chronic Peritoneal Dialysis

Borzych-Dużałka

Bilginer

et al. 2013

Journal of the American Society of Nephrology

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“…When even mild renal insufficiency is associated with other risk factors for cardiovascular disease, the risk of subsequent cardiovascular events is significantly increased (2)(3)(4)(5)(6)(7)(8)(9)(10). The effect of mild renal insufficiency (serum creatinine levels of Ͼ124 M) on cardiovascular risk is possibly also independent of other known risk factors and treatment (11)(12)(13)(14)(15). For patients established on dialysis, cardiovascular disease is responsible for up to 50% of the all-cause mortality rate (16,17).…”

mentioning

confidence: 99%

Effects of Early and Late Intervention with Epoetin α on Left Ventricular Mass among Patients with Chronic Kidney Disease (Stage 3 or 4)

Roger¹,

McMahon²,

Clarkson³

et al. 2004

Journal of the American Society of Nephrology

197

115

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Abstract. It is not known whether prevention of anemia among patients with chronic kidney disease would affect the development or progression of left ventricular (LV) hypertrophy. A randomized controlled trial was performed with 155 patients with chronic kidney disease (creatinine clearance, 15 to 50 ml/min), with entry hemoglobin concentrations ([Hb]) of 110 to 120 g/L (female patients) or 110 to 130 g/L (male patients). Patients were monitored for 2 yr or until they required dialysis; the patients were randomized to receive epoetin ␣ as necessary to maintain [Hb] between 120 and 130 g/L (group A) or between 90 and 100 g/L (group B). [Hb] increased for group A (from 112 Ϯ 9 to 121 Ϯ 14 g/L, mean Ϯ SD) and decreased for group B (from 112 Ϯ 8 to 108 Ϯ 13 g/L) (P Ͻ 0.001, group A versus group B). On an intent-to-treat analysis, the changes in LV mass index for the groups during the 2-yr period were not significantly different (2.5 Ϯ 20 g/m 2 for group A versus 4.5 Ϯ 20 g/m 2 for group B, P ϭ NS). There was no significant difference between the groups in 2-yr mean unadjusted systolic BP (141 Ϯ 14 versus 138 Ϯ 13 mmHg) or diastolic BP (80 Ϯ 6 versus 79 Ϯ 7 mmHg). The decline in renal function in 2 yr, as assessed with nuclear estimations of GFR, also did not differ significantly between the groups (8 Ϯ 9 versus 6 Ϯ 8 ml/min per 1.73 m 2 ). In conclusion, maintenance of [Hb] above 120 g/L, compared with 90 to 100 g/L, had similar effects on the LV mass index and did not clearly affect the development or progression of LV hypertrophy. The maintenance of [Hb] above 100 g/L for many patients in group B might have been attributable to the relative preservation of renal function.Chronic kidney disease (CKD) is widespread in the community, with a prevalence far exceeding previous estimates (1). Many studies examining mortality and morbidity rates among patients with CKD have identified high rates of cardiovascular events. When even mild renal insufficiency is associated with other risk factors for cardiovascular disease, the risk of subsequent cardiovascular events is significantly increased (2-10). The effect of mild renal insufficiency (serum creatinine levels of Ͼ124 M) on cardiovascular risk is possibly also independent of other known risk factors and treatment (11)(12)(13)(14)(15). For patients established on dialysis, cardiovascular disease is responsible for up to 50% of the all-cause mortality rate (16,17). It is therefore important to attempt to reduce the incidence of cardiovascular events with risk factor modification before the onset of dialysis.Left ventricular (LV) hypertrophy (LVH) is recognized as a powerful independent predictor of death and morbidity in the dialysis population, together with anemia, hypertension, malnutrition, hyperparathyroidism, and an elevated calcium-phos-

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“…[9][10][11][12][13] Recent ESA research calls into question previous findings showing ESA administration to be renal protective in CKD patients. [19][20] Although the hemoglobin level targets have and will vary with the publication of new evidence, the important issue reported herein is the need to ensure accurate reporting of clinical parameters in order to guide medical decisionmaking based on contemporary guidelines. A valid predialysis ESA care indicator is especially relevant now because it can be used in studies investigating anemia management and the quality of patient care.…”

Section: Discussionmentioning

confidence: 99%

Form CMS-2728 Data Versus Erythropoietin Claims Data: Implications for Quality of Care Studies

et al. 2012

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Medical Evidence Report Form CMS-2728 data is frequently used to study US dialysis patients, but the validity of these data have been called into question. We compared predialysis erythropoietin use as recorded on Form CMS-2728 with claims data as part of an assessment of quality of care among hemodialysis patients. Medicare claims were linked to Form CMS-2728 data for 18,870 patients. Dialysis patients, 67 years old or older, who started dialysis from 1 June 2005 to 31 May 2007 were eligible. Logistic and multivariate regressions were used to compare the use of either Form CMS-2728 or the corresponding claims data to predict mortality and the probability of meeting target hemoglobin levels. The sensitivity, specificity, and kappa coefficient for the predialysis erythropoietin indicator were 58.0%, 78.4%, and 0.36, respectively. Patients with a predialysis erythropoietin claim were less likely to die compared with patients without a claim (odds ratio ¼ 0.80 and 95% confidence interval ¼ 0.74-0.87), but there was no relationship observed between predialysis care and death using only Form CMS-2728 predictors. At the facility level, a predialysis erythropoietin claim was associated with a 0.085 increase in the rate of meeting target hemoglobin levels compared with patients without a claim (p ¼ 0.041), but no statistically significant relationship was observed when using the Form CMS-2728 indicators. The agreement between Form CMS-2728 and claims data is poor and discordant results are observed when comparing the use of these data sources to predict health outcomes. Facilities with higher agreement between the two data sources may provide greater quality of care.

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Use of Erythropoietin Before the Initiation of Dialysis and Its Impact on Mortality

Cited by 138 publications

References 12 publications

Management of Anemia in Children Receiving Chronic Peritoneal Dialysis

Management of Anemia in Children Receiving Chronic Peritoneal Dialysis

Effects of Early and Late Intervention with Epoetin α on Left Ventricular Mass among Patients with Chronic Kidney Disease (Stage 3 or 4)

Form CMS-2728 Data Versus Erythropoietin Claims Data: Implications for Quality of Care Studies

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