Use of the esa resistance index to guide dosing for anaemia management

Abstract

SUMMARY Background Identifying erythropoiesis‐stimulating agent (ESA) resistance is important for treating reversible causes, reaching target haemoglobin levels with minimal dosing, avoiding adverse effects and reducing costs. The resistance index (RI, dose/kg weight/g haemoglobin/dl) is reportedly superior to absolute or weight‐based dosing. Objectives With the growing number of ESA classes and medications, our goal was to develop methodology to establish RI ranges in otherwise healthy haemodialysis patients as a structured approach to identify remediable causes of anaemia. Design We retrospectively studied anaemia management with darbepoetin in 100 chronic haemodialysis patients and a subgroup of 48 without identifiable conditions that impair erythropoiesis. Data included inflammatory and bone marrow conditions, medications with hematologic effects, catheter use, iron, parathyroid and dialysis measures. Results The haematologically healthy group was aged 57.1 ± 1.9 SEM years, 33% diabetic, with haemoglobin 10.4 ± 0.2 g/dl. The darbepoetin RI (DRI) values were 0.05 ± 0.01, absolute dose 38.5 ± 3.5 mcg/week and weight‐based 0.50 ± 0.05 mcg/kg. Regression analyses included iron saturation, ferritin, parathyroid hormone and urea reduction ratio. DRI was superior to other dosing approaches based on the distribution of results (kurtosis) and discordance between the measures that occurred in 17% of patients at haemoglobin target. Conclusions We demonstrate the value of determining the RI for use with expanding ESA choices, using as an example how DRI values can be established for healthy haemodialysis patients so as to guide dosing. When elevated, the RI can trigger evaluation for remediable factors causing hyporesponsiveness even when haemoglobin goals have been reached.

Tibial Lead Levels and Erythropoiesis Stimulating Agent Dosing among 75 Patients with End-Stage Kidney Disease

“…ESA dosing was examined as a proportion receiving a dose above the cohort median ( ), continuously, and by a resistance index that normalized for body weight and hemoglobin concentrations, as these two factors are strong determinants of ESA dosing. 8 We used the most recently available hemoglobin concentrations, typically measured once or twice monthly, and estimated body weight, adjudicated monthly by the nephrology team, from outpatient dialysis records prior to hospitalization. Additional characteristics were extracted by inpatient electronic medical record review [self-reported age, sex assigned at birth (male, female), race/ethnicity (white, black, Hispanic, other race)], outpatient dialysis record review [central venous catheter (CVC), arteriovenous fistula (AVF) or graft (AVG), total iron-binding capacity (TIBC)], participant interview [education ( grade, college or higher), tobacco history (past/present use, never)], and physical examination [edema (none, , )].…”

Household Water Lead and Hematologic Toxic Effects in Chronic Kidney Disease

“…Dosing of ESA was examined at the maximum monthly recommended dosing per package guidelines (360 μg/mo or higher) 19 continuously and, because hemoglobin concentration and body weight are the major determinants of ESA dosing, by ESA resistance, which divides the mean monthly ESA dose by the product of mean monthly hemoglobin concentration and body weight (kilograms). 20 To limit extreme outliers, values were winsorized at the 99.5th percentile.…”

“…However, household lead contamination is generally chronic and stable, the kidney failure population tends to be geographically constrained to their dialysis centers, and we included a sample size large enough to detect even underestimated associations. In addition, other sources of lead, such as lead paint, were not .12 2018 476 (20) 42 (25) 12 (24) 10 ( 26)…”