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Desai R, Unigwe I, Riaz M, Smith SM, Shukla AM, Mohandas R, Jeon N, Park H. Comparative Safety of Long-Acting vs. Short-Acting Erythropoiesis-Stimulating Agents Among Patients Undergoing Hemodialysis. Clin Pharmacol Ther 2024; 116:217-224. [PMID: 38629679 DOI: 10.1002/cpt.3271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/30/2024] [Indexed: 05/30/2024]
Abstract
Both short-acting (epoetin alfa or beta) and long-acting (darbepoetin alfa or PEG-epoetin) erythropoiesis-stimulating agents (ESAs) are commonly prescribed for patients with kidney failure undergoing maintenance hemodialysis. We compared the risks of major adverse cardiovascular events (MACE) and of all-cause mortality associated with receipt of short- vs. long-acting ESAs. This retrospective cohort analysis included Medicare hemodialysis beneficiaries aged ≥ 18 years in the United States Renal Data System from January 2015 to December 2017. We included adults who survived > 90 days after initiating hemodialysis and received either short- or long-acting ESAs. Outcomes were MACE (first occurrence of stroke, acute myocardial infarction, or cardiovascular-related mortality) and all-cause mortality. After stabilized inverse probability of treatment weighting, Cox proportional hazards regression models were used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for each outcome. Of 68,607 patients (mean age: 65 years, 45% females), 33,658 (49%) received long-acting ESAs and 34,949 (51%) received short-acting ESAs. There was no difference in the risk of MACE associated with receipt of short- vs. long-acting ESAs (HR: 1.02 (95% CI: 0.98-1.08)). However, long-acting (vs. short-acting) ESA receipt was associated with a lower risk of all-cause mortality (HR: 0.91 (95% CI: 0.87-0.96)). Compared with short-acting ESAs, long-acting ESAs were associated with a lower risk of all-cause mortality, with no difference in the risk of MACE. Future studies with a longer follow-up are needed to confirm these findings.
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Affiliation(s)
- Raj Desai
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Ikenna Unigwe
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Munaza Riaz
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Steven M Smith
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Ashutosh M Shukla
- College of Medicine, University of Florida, Gainesville, Florida, USA
- North Florida South Georgia Veterans Healthcare System, Gainesville, Florida, USA
| | - Rajesh Mohandas
- Division of Nephrology and Hypertension, Louisiana State University Health Sciences Center School of Medicine, New Orleans, Louisiana, USA
| | - Nakyung Jeon
- College of Pharmacy and Research Institute for Drug Development, Pusan National University, Busan, Korea
| | - Haesuk Park
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
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Cases A, Sánchez EGDA, Cadeddu G, Lorenzo MM. Epidemiology and treatment of renal anaemia in Spain: RIKAS retrospective study. Nefrologia 2023; 43:562-574. [PMID: 37914638 DOI: 10.1016/j.nefroe.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/02/2022] [Accepted: 04/01/2022] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Studies on the prevalence of anaemia in chronic kidney disease in adults not on dialysis (CKD-ND) and in dialysis programmes (CKD-D) in Spain are not recent or focus on certain subgroups. The aim of this study was to know the epidemiology and current treatment patterns of anaemia associated with CKD in Spain. MATERIALS AND METHODS Multicentre, non-interventional, retrospective study with CKD-ND stage 3a-5 and CKD-D patients treated in Spain between 2015 and 2017 (RIKAS study). RESULTS The prevalence of anaemia in CKD-ND and CKD-D in 2015 was 33.8% and 91.5%, respectively, with similar results during 2016-2017. The prevalence of systemic inflammation in anaemic patients (18.1% and 51.8% for CKD-ND and CKD-D, respectively) was higher, especially in those treated with erythropoiesis-stimulating agents (ESA), compared to the general population with CKD-ND. After 12 months of follow-up, mean ferritin and transferrin saturation index (TSI) values in anaemic patients with CKD-ND were 187.1 ng/mL and 22.2%, respectively, while in CKD-D were 254.6 ng/mL and 20.2%. In ESA-treated patients, mean values were 190.6 ng/mL and 22.0% in ND-CKD, and 255.0 ng/mL and 20.2% in D-CKD. CONCLUSIONS The prevalence of anaemia and inflammation increased with the disease severity, being higher in D-CKD. Iron parameters in anaemic patients treated or not with ESA are insufficient according to the guidelines, so there is room for improvement in the treatment of anaemia associated with CKD.
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Affiliation(s)
- Aleix Cases
- Departament de Medicina, Universitat de Barcelona, Barcelona, Spain; Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Grupo de Anemia de la S.E.N., Spain.
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Cases A, González de Antona Sánchez E, Cadeddu G, Mata Lorenzo M. Epidemiología y tratamiento de la anemia renal en España: estudio retrospectivo RIKAS. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Guía de unidades de hemodiálisis 2020. Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Minutolo R, Garofalo C, Chiodini P, Aucella F, Del Vecchio L, Locatelli F, Scaglione F, De Nicola L. Types of erythropoiesis-stimulating agents and risk of end-stage kidney disease and death in patients with non-dialysis chronic kidney disease. Nephrol Dial Transplant 2021; 36:267-274. [PMID: 32829405 DOI: 10.1093/ndt/gfaa088] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/14/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Despite the widespread use of erythropoiesis-stimulating agents (ESAs) to treat anaemia, the risk of adverse outcomes associated with the use of different types of ESAs in non-dialysis chronic kidney disease (CKD) is poorly investigated. METHODS From a pooled cohort of four observational studies, we selected CKD patients receiving short-acting (epoetin α/β; n = 299) or long-acting ESAs (darbepoetin and methoxy polyethylene glycol-epoetin β; n = 403). The primary composite endpoint was end-stage kidney disease (ESKD; dialysis or transplantation) or all-cause death. Multivariable Cox models were used to estimate the relative risk of the primary endpoint between short- and long-acting ESA users. RESULTS During follow-up [median 3.6 years (interquartile range 2.1-6.3)], the primary endpoint was registered in 401 patients [166 (72%) in the short-acting ESA group and 235 (58%) in the long-acting ESA group]. In the highest tertile of short-acting ESA dose, the adjusted risk of primary endpoint was 2-fold higher {hazard ratio [HR] 2.07 [95% confidence interval (CI) 1.37-3.12]} than in the lowest tertile, whereas it did not change across tertiles of dose for long-acting ESA patients. Furthermore, the comparison of ESA type in each tertile of ESA dose disclosed a significant difference only in the highest tertile, where the risk of the primary endpoint was significantly higher in patients receiving short-acting ESAs [HR 1.56 (95% CI 1.09-2.24); P = 0.016]. Results were confirmed when ESA dose was analysed as continuous variable with a significant difference in the primary endpoint between short- and long-acting ESAs for doses >105 IU/kg/week. CONCLUSIONS Among non-dialysis CKD patients, the use of a short-acting ESA may be associated with an increased risk of ESKD or death versus long-acting ESAs when higher ESA doses are prescribed.
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Affiliation(s)
- Roberto Minutolo
- Division of Nephrology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Carlo Garofalo
- Division of Nephrology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Paolo Chiodini
- Medical Statistics Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Filippo Aucella
- Department of Nephrology and Dialysis, IRCSS "Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Italy
| | | | - Francesco Locatelli
- Past Director of the Department of Nephrology and Dialysis, AlessandroManzoni Hospital, ASST Lecco, Lecco, Italy
| | - Francesco Scaglione
- Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
| | - Luca De Nicola
- Division of Nephrology, University of Campania Luigi Vanvitelli, Naples, Italy
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Karaboyas A, Port FK, Massy ZA, Locatelli F, Cases A, Nitta K, Liabeuf S, Jager KJ, Robinson BM. Long- Versus Short-Acting Erythropoiesis-Stimulating Agent Type and Mortality. Kidney Int Rep 2020; 6:214-218. [PMID: 33426400 PMCID: PMC7783558 DOI: 10.1016/j.ekir.2020.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/15/2020] [Accepted: 10/05/2020] [Indexed: 01/05/2023] Open
Affiliation(s)
- Angelo Karaboyas
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Friedrich K Port
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Ziad A Massy
- Ambroise Paré University Hospital, Assistance publique Hôpitaux de Paris, Department of Nephrology Boulogne-Billancourt/Paris, and Institut national de la santé et de la recherche médicale Unit 1018, Team 5, CESP, Saclay University, and Versailles Saint-Quentin-en-Yvelines University, Paris-Ile-de-France-West University, Villejuif, France
| | - Francesco Locatelli
- Alessandro Manzoni Hospital, Department of Nephrology, past director, ASST Lecco, Lecco, Italy
| | - Aleix Cases
- Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Sophie Liabeuf
- Pharmacology Department, Amiens University Hospital and MP3CV Laboratory, EA7517, University of Picardie Jules Verne, Amiens, France
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam UMC, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, the Netherlands
| | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA.,University of Michigan, Department of Internal Medicine, Ann Arbor, Michigan, USA
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Ross EA, Paugh-Miller JL, Wen X, Nappo RW. Use of the esa resistance index to guide dosing for anaemia management. J Ren Care 2020; 46:216-221. [PMID: 32219971 DOI: 10.1111/jorc.12324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Edward A Ross
- Department of Internal Medicine, University of Central Florida, Orlando, Florida, USA
| | - Jennifer L Paugh-Miller
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida, USA
| | - Xuerong Wen
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - Robert W Nappo
- University of Florida Shands Hospital, Gainesville, Florida, USA
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Lee JH, Ha Chung B, Joo KW, Shin SK, Kim YL, Na KY, Do JY, Park SK, Shin BC, Lee JS, Kim YW, Kim SW, Lee KW, Kang GW, An WS, Shin GT, Han S, Yang CW. Efficacy and safety of CKD-11101 (darbepoetin-alfa proposed biosimilar) compared with NESP in anaemic chronic kidney disease patients not on dialysis. Curr Med Res Opin 2019; 35:1111-1118. [PMID: 30569763 DOI: 10.1080/03007995.2018.1560134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of CKD-11101 (biosimilar darbepoetin-alfa, Chong Kun Dang Pharm.) compared with NESP® in treatment of anaemia in patients with chronic kidney disease not on dialysis. CLINICAL TRIAL REGISTRATION NCT03431623. METHOD In this multi-centre, randomized, double-blind study, patients were treated with CKD-11101 and NESP. The efficacy evaluation period (EEP) was 24 weeks, during which patients were treated every 2 weeks. All patients who completed the EEP were treated with CKD-11101 every 2 weeks for the first 4 weeks and every 4 weeks for the safety evaluation period (SEP), which was from 24 weeks to 52 weeks. The primary efficacy endpoint was the change in mean haemoglobin (Hb) level from baseline to end of EEP and mean dose needed to achieve the target Hb. RESULTS The mean Hb level was increased in both groups during the EEP (both p < 0.001). The difference in mean Hb level change between the two groups was 0.01 g/dL (95% CI = -0.213-0.242), indicating that CKD-11101 was equivalent to NESP. The difference in mean administration dose between groups was -1.40 mcg (95% CI = -6.859-4.059) included in the equivalent range. The incidence of AEs and ADRs was not different between the two groups, and the frequency of ADRs was favourable in both groups (1.2% in CKD-11101 vs 7.7% in the NESP to CKD-11101 conversion group). CONCLUSION CKD-11101 has an equivalent therapeutic effect as NESP in chronic kidney disease patients with renal anaemia. CKD-11101 can be safely used for long-term treatment and in patients converted from NESP.
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Affiliation(s)
- Jong Hoon Lee
- a Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine , The Catholic University of Korea , Seoul , Korea
| | - Byung Ha Chung
- a Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine , The Catholic University of Korea , Seoul , Korea
| | - Kwon Wook Joo
- b Division of Nephrology, Department of Internal Medicine , Seoul National University College of Medicine , Seoul , Korea
| | - Sug Kyun Shin
- c Division of Nephrology, Department of Internal Medicine , National Health Insurance Corporation IIsan Hospital , Goyang , Korea
| | - Yong-Lim Kim
- d Division of Nephrology, Department of Internal Medicine , Kyungpook National University School of Medicine , Daegu , Korea
| | - Ki Young Na
- e Division of Nephrology, Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Korea
| | - Jun-Young Do
- f Division of Nephrology, Department of Internal Medicine , Yeungnam University School of Medicine , Daegu , Korea
| | - Su-Kil Park
- g Division of Nephrology, Department of Internal Medicine , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Korea
| | - Byung Chul Shin
- h Division of Nephrology, Department of Internal Medicine, College of Medicine , Chosun University , Gwangju , Korea
| | - Jong Soo Lee
- i Division of Nephrology, Department of Internal Medicine , Ulsan University Hospital , Ulsan , Korea
| | - Yang-Wook Kim
- j Division of Nephrology, Department of Internal Medicine , Inje University, Haeundae Paik Hospital , Busan , Korea
| | - Soo Wan Kim
- k Division of Nephrology, Department of Internal Medicine , Chonnam National University Medical School , Gwangju , Korea
| | - Kang Wook Lee
- l Division of Nephrology, Department of Internal Medicine , Chungnam National University Hospital , Daejeon , South Korea
| | - Gun Woo Kang
- m Division of Nephrology, Department of Internal Medicine , Catholic University of Daegu School of Medicine , Daegu , Korea
| | - Won Suk An
- n Division of Nephrology, Department of Internal Medicine, College of Medicine , Dong-A University , Busan , Korea
| | - Gyu-Tae Shin
- o Division of Nephrology, Department of Nephrology , Ajou University School of Medicine , Suwon , Korea
| | - Seungyeup Han
- p Division of Nephrology, Department of Internal Medicine , Keimyung University School of Medicine , Daegu , Korea
| | - Chul Woo Yang
- a Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine , The Catholic University of Korea , Seoul , Korea
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Coronado Daza JA, Cuchi GU. Gender Differences in Dose of Erythropoietin to Maintain Hemoglobin Target in Hemodialysis Patients. Indian J Nephrol 2019; 29:160-165. [PMID: 31142961 PMCID: PMC6521763 DOI: 10.4103/ijn.ijn_124_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Dialysis patients receiving erythropoietin (EPO) for anemia management are a challenge due to the significant interindividual variability in erythropoietic response. Our objective was to determine if there is a gender-dependent difference in the EPO doses required to maintain the hemoglobin (Hb) targets in adult patients undergoing hemodialysis. We conducted a historic cohort study with a 12-month follow-up. We include patients with the Hb target, normal serum albumin, and normal transferrin saturation index. Monthly data were gathered for the following: Hb level, EPO doses, and intravenous iron doses. In the 11 hemodialysis facilities included, 1844 patients were on hemodialysis. We considered 389 patients for follow-up, 190 of which were excluded mainly for failing to keep the Hb level in the established range. The final cohort for analysis included 141 men (70.9%) and 58 women (29.1%). At baseline, men weighed more than women (P < 0.001). At the end of the follow-up period, the EPO required to maintain Hb level between 10 and 13 g/dl was significantly higher in women in the monthly dose, weekly dose, and weekly EPO dose/patient weight, with no difference in the monthly iron dose. There was a significant association between female gender and the use of high EPO doses (odds ratio, 4.1; 95% confidence interval, 1.4–12.2; P = 0.01). Our study demonstrates that women require higher doses of EPO to achieve Hb targets.
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Affiliation(s)
- J A Coronado Daza
- Faculty of Medicine, Medical Department, University of Cartagena, Cartagena, Colombia
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Yamasaki A, Yoda K, Koyama H, Yamada S, Tsujimoto Y, Okuno S, Okada S, Inaba M. Association of Erythropoietin Resistance with Fatigue in Hemodialysis Patients: A Cross-Sectional Study. Nephron Clin Pract 2016; 134:95-102. [PMID: 27424040 DOI: 10.1159/000448108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 06/27/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Fatigue is a common symptom in patients receiving hemodialysis (HD) and is generally associated with anemia. However, it can be difficult to resolve, even when anemia has been treated using erythropoiesis-stimulating agents and iron replacement therapy. In the present study, we examined the associations of anemia, the erythropoietin resistance index (ERI) and iron deficiency with fatigue during HD. METHODS In this cross-sectional study, fatigue score was calculated on the basis of questionnaire responses in HD patients. Participants were divided into 3 groups according to their hemoglobin (Hb) levels (low, normal and high). Iron deficiency was assessed as a transferrin saturation (TSAT) of <20%. RESULTS We included 571 HD patients (men/women 368/203; mean age 62.2 ± 10.8 years). Among the 3 groups, fatigue scores increased significantly with decreasing Hb levels. HD patients with low Hb levels (<90 g/l) had significantly higher fatigue scores than those with higher Hb levels (≥120 g/l). In the multiple regression analysis, we showed that a high ERI (β = 0.208) and a low TSAT (β = -0.155), but not the Hb level, were significantly associated with increased fatigue score. Moreover, this was independent of age, gender and modifiable confounders linked to anemia. Even after restricting patients to those without iron deficiency (TSAT ≥20%), the ERI (β = 0.258) retained a significant and independent association with the fatigue score. CONCLUSION Iron deficiency and a high ERI despite iron sufficiency may cause fatigue in HD patients.
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Affiliation(s)
- Akiyo Yamasaki
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
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Hara K, Mizutani Y, Kodera H, Miyake M, Yasuda Y, Ohara S. Successful creation of an anemia management algorithm for hemodialysis patients. Int J Nephrol Renovasc Dis 2015; 8:65-75. [PMID: 26150734 PMCID: PMC4484653 DOI: 10.2147/ijnrd.s80723] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Several anemia guidelines for hemodialysis patients have recommended a target hemoglobin (Hb) range of 10-12 g/dL. However, maintaining Hb values continuously within a narrow target has been difficult, and there has been no generally accepted anemia management algorithm for hemodialysis patients. METHODS In our study, we created an anemia management algorithm that considers the length of erythrocyte lifetimes, focuses on the combination of erythropoiesis-stimulating agent management and iron administration, and prevents iron deficiency and overload. Our algorithm established a target Hb range of 10-12 g/dL. RESULTS We evaluated our algorithm in 49 patients for 6 months. The mean Hb values were approximately 11 g/dL during our study period. The percentage of patients in the target Hb range of 10-12 g/dL increased from 77.6% (38 of 49) at baseline to 85.7% (42 of 49) at 4-6 months. Throughout monthly regular blood tests during 1-6 months after we introduced our algorithm, Hb values remained within the target range in 55.1% (27 of 49) of patients. The standard deviation of Hb values significantly decreased at 5 and 6 months (P=0.013 and P=0.047, respectively; 1 g/dL at 0 month, 0.7 g/dL at 5 months, and 0.7 g/dL at 6 months). Our algorithm also succeeded in suppressing cumulative doses of iron (≤800 mg) and decreasing the ferritin values significantly (P=0.011). There were no significant differences in erythropoiesis-stimulating agent doses between 0 and 6 months (P=0.357). CONCLUSION Our anemia management algorithm successfully increased the number of patients in the target Hb range, significantly decreased the Hb standard deviation, suppressed cumulative doses of iron, and decreased ferritin values. These results suggest a better prognosis for hemodialysis patients. Further studies are required to evaluate our algorithm.
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Affiliation(s)
- Kazuhiro Hara
- Department of Nephrology, Yokkaichi Social Insurance Hospital, Yokkaichi, Mie Prefecture, Japan
| | - Yasuhide Mizutani
- Department of Nephrology, Yokkaichi Social Insurance Hospital, Yokkaichi, Mie Prefecture, Japan
| | - Hitoshi Kodera
- Department of Nephrology, Yokkaichi Social Insurance Hospital, Yokkaichi, Mie Prefecture, Japan
| | - Masato Miyake
- Department of Nephrology, Yokkaichi Social Insurance Hospital, Yokkaichi, Mie Prefecture, Japan
| | - Yoshiki Yasuda
- Department of Nephrology, Yokkaichi Social Insurance Hospital, Yokkaichi, Mie Prefecture, Japan
| | - Sanae Ohara
- Department of Nephrology, Yokkaichi Social Insurance Hospital, Yokkaichi, Mie Prefecture, Japan
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Ito K, Ookawara S, Ueda Y, Goto S, Miyazawa H, Yamada H, Kitano T, Shindo M, Kaku Y, Hirai K, Yoshida M, Hoshino T, Nabata A, Mori H, Yoshida I, Kakei M, Tabei K. Factors affecting cerebral oxygenation in hemodialysis patients: cerebral oxygenation associates with pH, hemodialysis duration, serum albumin concentration, and diabetes mellitus. PLoS One 2015; 10:e0117474. [PMID: 25706868 PMCID: PMC4338103 DOI: 10.1371/journal.pone.0117474] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 12/24/2014] [Indexed: 01/13/2023] Open
Abstract
Background Patients undergoing hemodialysis (HD) often develop cerebral disease complications. Furthermore, cerebral regional saturation of oxygen (rSO2) was previously reported to be significantly lower in HD patients than in healthy subjects. We aimed to identify the factors affecting the cerebral rSO2 in HD patients. Methods Fifty-four HD patients (38 men and 16 women; mean age, 67.7 ± 1.2 years, HD duration, 6.5 ± 1.9 years) were recruited. Cerebral rSO2 was monitored at the forehead before HD using an INVOS 5100C (Covidien Japan, Tokyo, Japan). Results The rSO2 levels were significantly lower in HD patients compared with healthy controls (49.5 ± 1.7% vs. 68.9 ± 1.6%, p <0.001). Multiple regression analysis showed that cerebral rSO2 independently associated with pH (standardized coefficient: -0.35), HD duration (standardized coefficient: -0.33), and serum albumin concentration (standardized coefficient: 0.28). Furthermore, the rSO2 was significantly lower in HD patients with diabetes mellitus (DM), compared with patients without DM (46.8 ± 1.7% vs. 52.1 ± 1.8%, p <0.05). Conclusions In HD patients, cerebral rSO2 was affected by multiple factors, including pH, HD duration, and serum albumin concentration. Furthermore, this is the first report describing significantly lower levels of rSO2 in HD patients with DM than in those without DM.
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Affiliation(s)
- Kiyonori Ito
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Susumu Ookawara
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
- Department of Internal Medicine, Nishikawa Town Hospital, Yamagata, Japan
- * E-mail:
| | - Yuichiro Ueda
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Sawako Goto
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Haruhisa Miyazawa
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hodaka Yamada
- Division of Endocrinology and Metabolism, Department of Integrated Medicine Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Taisuke Kitano
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Mitsunobu Shindo
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yoshio Kaku
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Keiji Hirai
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Masashi Yoshida
- Division of Endocrinology and Metabolism, Department of Integrated Medicine Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Taro Hoshino
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Aoi Nabata
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Honami Mori
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Izumi Yoshida
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Masafumi Kakei
- Division of Endocrinology and Metabolism, Department of Integrated Medicine Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kaoru Tabei
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Wilhelm-Leen ER, Winkelmayer WC. Mortality risk of darbepoetin alfa versus epoetin alfa in patients with CKD: systematic review and meta-analysis. Am J Kidney Dis 2015; 66:69-74. [PMID: 25636816 DOI: 10.1053/j.ajkd.2014.12.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 12/21/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Epoetin alfa (EPO) and darbepoetin alfa (DPO) are erythropoiesis-stimulating agents that are widely and interchangeably used for the treatment of anemia in patients with advanced chronic kidney disease and end-stage renal disease. No study has specifically compared the risks of hard study outcomes between EPO and DPO, including mortality. STUDY DESIGN Systematic review of the literature and meta-analysis. SETTING & POPULATION Patients enrolled in randomized trials comparing EPO versus DPO for the treatment of anemia in adults with chronic kidney disease, including those requiring dialysis. SELECTION CRITERIA FOR STUDIES We conducted a systematic search of the literature (PubMed, CENTRAL, SCOPUS, and EMBASE, all years) and industry resources, using predefined search terms and data abstraction tools. We then summarized key characteristics and findings of these trials and performed a random-effects meta-analysis of trials with at least 3 months' duration to identify the summary OR of mortality between patients randomly assigned to DPO versus EPO. INTERVENTION DPO versus EPO. OUTCOME All-cause mortality. RESULTS We identified 9 trials that met the stated inclusion criteria. Overall, 2,024 patients were included in the meta-analysis, of whom 126 died during follow-up, which ranged from 20 to 52 weeks. We found no significant difference in mortality between patients randomly assigned to DPO versus EPO (OR, 1.33; 95% CI, 0.88-2.01). No treatment heterogeneity across studies was detected (Q statistic=4.60; P=0.8). LIMITATIONS Generalizability to nontrial populations is uncertain. CONCLUSIONS Few trials directly comparing DPO and EPO have been conducted and follow-up was limited. In aggregate, no effect of specific erythropoiesis-stimulating agent on mortality was identified, but the confidence limits were wide and remained compatible with considerable harm from DPO. Absent adequately powered randomized trials, observational postmarketing comparative effectiveness studies comparing these erythropoiesis-stimulating agents are required to better characterize the long-term safety profiles of these agents.
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Affiliation(s)
| | - Wolfgang C Winkelmayer
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA; Section of Nephrology, Baylor College of Medicine, Houston, TX.
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Beneficial dose conversion after switching from higher doses of shorter-acting erythropoiesis-stimulating agents to C.E.R.A in CKD patients in clinical practice: MINERVA Study. Int Urol Nephrol 2014; 46:1983-95. [PMID: 25118611 DOI: 10.1007/s11255-014-0800-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 07/24/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE To assess whether the correction dose recommended by the summary of product characteristics was adequate and to confirm the adequacy of the recommended conversion dosing strategies from shorter-acting erythropoiesis-stimulating agents (ESAs) to continuous erythropoietin receptor activator (C.E.R.A) in anaemic chronic kidney disease (CKD) patients in the clinical setting. METHODS This was a 12-month, multicenter, prospective, observational study in anaemic CKD patients on haemodialysis and not on dialysis receiving C.E.R.A (at least one dose). RESULTS A total of 227 patients were included (not on dialysis; n = 142; haemodialysis: n = 85). The present analysis was conducted on ESA-naïve patients (not on dialysis: n = 31) and patients switched from other ESA (not on dialysis: n = 63; haemodialysis: n = 57). Both on and not on dialysis patients switched from other ESA received lower starting C.E.R.A doses than those recommended, and remained stable during the 12-month period. The higher the previous ESA dose was, the more beneficial the C.E.R.A dose conversion factor was. The proportion of patients with stable haemoglobin within the target range (11-13 g/dL) did not vary during the 12-month period both in nondialysis CKD patients and in those undergoing dialysis [baseline: 42 (66.7 %) and 34 (59.6 %); month 6: 21 (55.3 %) and 26 (50.0 %); month 12: 20 (64.5 %) and 25 (69.4 %), respectively]. In naïve patients, the mean weight-adjusted C.E.R.A dose during the study (1.19 ± 0.49 µg/kg/month) was similar to the recommended one. C.E.R.A was well tolerated. CONCLUSIONS Conversion from shorter-acting ESAs to C.E.R.A doses lower than those recommended can efficiently maintain target haemoglobin levels both in nondialysis and haemodialysis CKD patients, particularly when switching from higher ESA doses. A monthly C.E.R.A dose of 1.2 µg/Kg seems adequate for anaemia correction.
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Stable hemoglobin in hemodialysis patients: forest for the trees--a 12-week pilot observational study. BMC Nephrol 2013; 14:243. [PMID: 24180578 PMCID: PMC4228386 DOI: 10.1186/1471-2369-14-243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2012] [Accepted: 10/28/2013] [Indexed: 12/30/2022] Open
Abstract
Background Hemoglobin (Hb) variability is a common occurrence in hemodialysis patients treated with erythropoiesis-stimulating agents. High amplitude fluctuations have been associated with greater risk of morbidity and mortality. Methods This prospective, single centre pilot observational study was conducted over a 3-month period in daily practice patterns, to assess per-dialysis events and inter-dialysis complications that could interfere with erythropoiesis in patients undergoing hemodialysis. Results Mean Hb levels remained stable in the 78 evaluable patients, as did darbepoetin alfa (DA) doses, including in patients suffering from diabetes or cardiac affections. In total, an average of 7.7 events / patient / month occurred, but no significant relationship with Hb excursions was shown. Conclusion The observation of 7.7 events per patient per month suggests a careful monitoring of Hb and DA dosing every other week, in order to maintain Hb level within the target.
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The MAINTAIN study--managing hemoglobin variability with darbepoetin alfa in dialysis patients experiencing a severe drop in hemoglobin. Wien Klin Wochenschr 2013; 125:71-82. [PMID: 23299452 DOI: 10.1007/s00508-012-0311-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 11/30/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Dialysis patients, receiving erythropoiesis stimulating agents, typically show signs of hemoglobin variability as a consequence of their dosing patterns, bleeding, infection, etc., which is commonly managed adjusting the dose regimen of the erythropoiesis stimulating agent. However, information on dosing strategies used in daily clinical practice and their outcomes in relation to hemoglobin variability is limited. OBJECTIVES To investigate clinical practice in Austria in relation with the management of hemoglobin variability, defined as a decrease of ³ 1 g/dL within 4 weeks from ³ 11 g/dL to £ 11 g/dL during maintenance therapy with darbepoetin alfa. The nature and incidence of clinical events related to the hemoglobin drop were also assessed. RESEARCH DESIGN AND METHODS The MAINTAIN non-interventional study was conducted in hemodialysis patients, receiving darbepoetin alfa in accordance to the label approved in the European Union at that time. Patient data were documented retrospectively for the 3 months prior to the hemoglobin drop. Data for the 6 months post hemoglobin drop were collected retrospectively or prospectively, depending on the time of patient inclusion respective to the Hb drop. RESULTS A hundred thirty six of 154 patients fulfilled all inclusion/exclusion criteria and had prospective documentation of 6 months. The main causes for the hemoglobin drop included surgical and medical procedures (36.1 %), and infections or infestations (24.4 %). The median treatment period was 273 days. The mean hemoglobin drop was - 1.74 g/dL (95 % confidence interval (CI): - 1.60 to - 1.87). Consequently, 81 % of the patients had their dose of darbepoetin alfa increased within a median Kaplan-Meier time to dose increase of 12.5 days (95 % CI: 6-22). The geometric mean weekly darbepoetin alfa dose increased by a factor of 1.1 from 29.1 mg (95 % CI: 24.6-34.4) in the 3 months before hemoglobin drop to 32.4 (95 % CI: 27.2-38.6) in months 4-6 post hemoglobin drop. Three patients had red blood cell transfusions before hemoglobin drop and nine patients after hemoglobin drop. The mean hemoglobin increase was 0.43 g/dL (95 % CI: 0.24-0.62) from immediately prior to 2 weeks after dose increase. The median Kaplan-Meier time to achieve a hemoglobin ³ 11 g/dL after hemoglobin drop was 36 days (95 % CI: 32-45). Frequent darbepoetin alfa dose adjustments were necessary to sustain maintenance levels. No drug-related adverse events were reported. CONCLUSIONS This observational study describes physicians' reactions to a drop in hemoglobin in clinical practice. Using darbepoetin alfa, the drop was generally compensated without leading to overcorrection.
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Kessler M, Landais P, Bataille P, Yver L, Koné S, Kraemer S, Brillet G, Canivet E. [Anemia management in French hemodialysis patients: DiaNE study results at 3 years (DiaNE2)]. Nephrol Ther 2011; 7:182-7. [PMID: 21227765 DOI: 10.1016/j.nephro.2010.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 11/16/2010] [Accepted: 11/25/2010] [Indexed: 11/26/2022]
Abstract
The observational study DiaNE provides a current state of anemia management with Epoetine bêta in hemodialysis patients regarding European recommendations over a 3-year period in France. Patients still treated with Epoetine bêta twelve months after their inclusion in DiaNE were eligible for a 24-month extension phase entitled DiaNE 2. Data regarding 439 patients followed during three years, from M0 to M36, were analyzed. Hemoglobin (Hb) level of the cohort remained over the target value of 11g/dL during the study (M0: 11.3±1.2g/dL; M36: 11.8±1.3g/dL). The anemia management had evolved with European recommendations updates and was in accordance with the last recommended target range (11-12g/dL) in a third of patients. During the follow-up, the majority of patients (97%) had at least one modification of treatment with Epoetine bêta (change in frequency of injections, adjustment of doses) mainly justified by excursion of Hb level out of the target range. However, the median dose of Epoetine bêta was relatively stable. The number of patients with iron treatment remained stable (60%). In spite of undertaken efforts, anemia management of hemodialysed patients in France still needs optimization for maintaining Hb level in the recommended target range.
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Complete correction of anemia by erythropoiesis-stimulating agents is associated with insulin resistance in hemodialysis patients. Clin Exp Med 2010; 11:181-7. [DOI: 10.1007/s10238-010-0119-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Accepted: 10/21/2010] [Indexed: 12/29/2022]
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