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Deak AT, Troppan K, Rosenkranz AR. Anemia management in cancer patients with chronic kidney disease. Eur J Intern Med 2016; 36:13-19. [PMID: 27640913 DOI: 10.1016/j.ejim.2016.08.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/06/2016] [Accepted: 08/19/2016] [Indexed: 12/27/2022]
Abstract
Anemia is a common complication of cancer and chronic kidney disease (CKD) associated with decreased physical performance as well as poor prognosis for life expectancy. Renal and cancer-induced anemia share common features regarding pathogenesis and therapeutic strategies. It is typically treated with iron substitution, erythropoiesis-stimulating agents (ESA) and in refractory cases with red blood cell transfusions. However, studies of the past few years unveiled numerous setbacks in the use of ESAs. These included a higher risk of cerebrovascular events and increased mortality without the improvement of cardiovascular outcomes in patients with CKD. Moreover, particularly negative results were observed in patients with previous cancer history under ESA therapy. These unfavorable findings have forced the clinicians to reevaluate the management of renal anemia. This led to decrease of ESA usage, while iron substitution and alternative therapeutic options gained more significance. Iron supplementation is also accompanied with certain risks ranging from gastrointestinal complications to severe allergic reactions and increased rate of infections. Furthermore, the evaluation of the long-term safety of excessive iron therapy is still lacking, especially in CKD patients with cancer. In the absence of these clinical studies, this review aims to summarize the currently available therapeutic strategies in anemia management of CKD patients with concomitant cancer.
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Affiliation(s)
- Andras T Deak
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 27, 8036 Graz, Austria
| | - Katharina Troppan
- Clinical Division of Haematology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 38, 8036 Graz, Austria
| | - Alexander R Rosenkranz
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 27, 8036 Graz, Austria.
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Pediatric Acute Kidney Injury: The Fight of Inadequate Education Versus Inadequate Literature. Pediatr Crit Care Med 2016; 17:808-10. [PMID: 27500622 DOI: 10.1097/pcc.0000000000000873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Beach LB, Wild M, Ramachandran G, Ikizler HO, Cavanaugh KL. Protocol of a randomized controlled trial of an erythropoietin stimulating agent decision aid for anemia treatment in kidney disease. BMC Nephrol 2016; 17:86. [PMID: 27430294 PMCID: PMC4949884 DOI: 10.1186/s12882-016-0301-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 07/01/2016] [Indexed: 11/10/2022] Open
Abstract
Background Erythropoiesis-stimulating agents (ESAs) are commonly used for the treatment of anemia due to chronic kidney disease (CKD) and end stage renal disease (ESRD). Patients often lack an understanding of the potential risks and benefits of ESAs, despite government mandated education on this topic. Decision aids are tools commonly used to discuss important information in health care settings. To address this knowledge gap, we designed this study to evaluate the effectiveness of a novel ESA decision aid at promoting informed shared decision making (ISDM) between patients and providers related to ESA use for CKD- and ESRD-related anemia. Methods Using the principles of informed shared decision making theory, we designed and piloted an ESA decision aid intended to increase CKD and ESRD patient understanding of the potential risks and benefits of ESAs. Informed by the findings during development, the ESA decision aid was modified and finalized for testing. We will perform a randomized clinical trial to assess if administration of the ESA decision aid improves patient understanding of the risks and benefits of ESA use compared to control patients receiving standard care. Participants with either CKD or ESRD and who are receiving ESAs will be eligible for participation. The primary outcome is patients’ score on the Patient Anemia Knowledge in Kidney Disease (PAKKD) survey assessed at enrollment and 3 months after. Secondary outcomes include decisional conflict related to ESAs, and patient satisfaction with provider communication. Discussion The Anemia Risk Communication for patients with Kidney Disease (ARC-KD) study will assess the effectiveness of a novel ESA decision aid to improve patient understanding of ESA use to manage CKD- and ESRD-related anemia. This decision aid is the first resource targeted to improve patient understanding of anemia management in the kidney health context. With the increasing options available for anemia management, this will serve as an important foundation to evolve in the future to optimize anemia-related shared decision making. Trial registration ClinicalTrials.gov, number NCT01992926. Registered 11/14/2013.
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Affiliation(s)
- Lauren B Beach
- Division of Nephrology & Hypertension, Vanderbilt University Medical Center, 1161 21st Avenue South, S-3223 MCN, Nashville, TN, 37232, USA.,Vanderbilt Center for Kidney Disease, Nashville, TN, USA
| | - Marcus Wild
- Division of Nephrology & Hypertension, Vanderbilt University Medical Center, 1161 21st Avenue South, S-3223 MCN, Nashville, TN, 37232, USA.,Vanderbilt Center for Kidney Disease, Nashville, TN, USA
| | | | - H Omer Ikizler
- University of Vermont College of Medicine, Burlington, VT, USA
| | - Kerri L Cavanaugh
- Division of Nephrology & Hypertension, Vanderbilt University Medical Center, 1161 21st Avenue South, S-3223 MCN, Nashville, TN, 37232, USA. .,Vanderbilt Center for Kidney Disease, Nashville, TN, USA.
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Hung SC, Lin YP, Tarng DC. Erythropoiesis-stimulating agents in chronic kidney disease: what have we learned in 25 years? J Formos Med Assoc 2013; 113:3-10. [PMID: 24090633 DOI: 10.1016/j.jfma.2013.09.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 08/22/2013] [Accepted: 09/02/2013] [Indexed: 10/26/2022] Open
Abstract
Since the pioneering studies by Eschbach et al in 1987, erythropoiesis-stimulating agents (ESAs) have become the mainstay of anemia therapy in chronic kidney disease (CKD) patients. The introduction of ESAs 25 years ago markedly improved the lives of many patients with CKD, who until then had severe, often transfusion-dependent anemia. However, randomized controlled trials demonstrate an increased risk for cardiovascular events such as stroke, thrombosis, and death at nearly normal hemoglobin concentrations and higher ESA doses in CKD. By contrast, kidney transplant recipients may represent a unique population of CKD patients who may benefit from ESA therapy. This review discusses potential mechanisms involving the erythropoietic and nonerythropoietic effects of ESA treatment and ESA resistance. Further research aimed at elucidating the causal pathways is strongly recommended. Given current knowledge, however, clinical practice should avoid disproportionately high dosages of ESAs to achieve recommended hemoglobin targets, particularly in those with significant cardiovascular morbidity or ESA resistance. The key to CKD anemia management will be individualization of the potential benefits of reducing blood transfusions and anemia-related symptoms against the risks of harm.
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Affiliation(s)
- Szu-Chun Hung
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Buddhist Tzu Chi University, Taipei, Taiwan
| | - Yao-Ping Lin
- Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Der-Cherng Tarng
- Division of Nephrology, Department of Medicine, and Immunology Research Center, Taipei Veterans General Hospital, Taipei, Taiwan; Department and Institute of Physiology, National Yang-Ming University, Taipei, Taiwan.
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Abstract
Renal anaemia is a frequent complication in patients with chronic kidney disease (CKD). Severe anaemia (haemoglobin <90 g/l) is associated with increased risks of mortality and cardiac complications, such as left ventricular hypertrophy and cardiovascular disease, and impaired quality of life. Randomized controlled trials have tested the hypothesis that increasing haemoglobin level using erythropoiesis-stimulating agents (ESAs) lowers these risks and improves quality of life. Use of ESAs to normalize haemoglobin levels (to ≥130 g/l) versus the partial correction of anaemia (to haemoglobin levels of 90-110 g/l) has repeatedly been shown to have no cardiac benefit and to be associated with no incremental improvement in outcomes and quality of life (except fatigue), but has been shown to be associated with an increased risk of cardiovascular events and death. Use of more-intense iron dosing has been proposed in order to reduce ESA dosing but liberal intravenous iron therapy is also associated with complications, and its long-term safety has not yet been adequately investigated. For patients with CKD on dialysis, US medication labels recommend administering ESAs at doses sufficient to avoid transfusions, whereas European and Canadian labels recommend targeting haemoglobin levels of 100-120 g/l and 110-120 g/l, respectively. Treatment of anaemia to haemoglobin levels of 90-110 g/l in patients with CKD accomplishes what we want--a reduced need for transfusions and possible reductions in fatigue, while avoiding high doses of ESA or iron in order to achieve a specific haemoglobin goal.
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Affiliation(s)
- Walter H Hörl
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
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Del Vecchio L, Locatelli F. Safety issues related to erythropoiesis-stimulating agents used to treat anemia in patients with chronic kidney disease. Expert Opin Drug Saf 2012; 11:923-31. [DOI: 10.1517/14740338.2012.712680] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Locatelli F, Vecchio LD. An expert opinion on the current treatment of anemia in patients with kidney disease. Expert Opin Pharmacother 2012; 13:495-503. [DOI: 10.1517/14656566.2012.658369] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Abstract
The four currently available erythropoiesis-stimulating agents (ESAs), the main drugs for correcting anemia in patients with chronic kidney disease (CKD), are epoetin alfa, epoetin beta, darbepoetin alfa, and continuous erythropoietin receptor activator. The last two have much longer half-lives, which means they can be administered less frequently. The expiry of the patents for epoetin alfa and epoetin beta some years ago opened up the way for the production of a number of biosimilars that are now marketed in the European Union. Because biosimilars cannot be identical to their originator, a complex and still-evolving regulatory policy has been generated, but there are still a number of issues concerning international naming, automatic substitution, and safety. All ESAs are effective in correcting renal anemia and increasing hemoglobin levels, but the choice of which to use should also take into account their pharmacokinetics and pharmacodynamics, their administration route, and economic issues. Following the publication of a number of trials indicating no benefit (and even possible harm) when ESAs are used to aim at near-normal hemoglobin levels in CKD patients, the hemoglobin target has become a major subject of discussion. According to the position statement of the Anemia Group of the European Renal Best Practice, it should generally be about 11-12 g/dL; however, a risk-benefit evaluation is warranted in individual patients, and high ESA doses driven by hyporesponsiveness should be avoided.
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Affiliation(s)
- Francesco Locatelli
- Department of Nephrology, Dialysis and Renal Transplant, Ospedale A. Manzoni, Via dell'Eremo 9, 23900 Lecco, Italy.
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Ziakka S, Zagorianakos A, Koutsovasili A, Kaperonis N, Poulikakos D, Sgantzos A, Kolovos V, Ntatsis G, Papagalanis N. Efficacy of hemopoietic-stimulating factors in patients undergoing chronic hemodialysis. Ren Fail 2011; 33:923-8. [PMID: 22013927 DOI: 10.3109/0886022x.2011.615963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Anemia has been linked to increased mortality and morbidity in renal hemodialysis patients. Other risk factors that contribute to an adverse outcome include the variability of hemoglobin (Hb) levels and the decreased response to erythropoiesis-stimulating factors (ESFs). In this study we evaluated the effectiveness of four different ESFs (epoetin-A, epoetin-B, darbepoetin, and CERA), assessed the variability of Hb levels, and compared ESF dosages which contributed to the achievement of Hb levels in each individual patient with renal failure undergoing chronic hemodialysis maintenance. In conclusion, the four ESFs administered are equally effective in the treatment of anemia in renal hemodialysis patients and they do not influence in a different manner the variability of Hb. The administration of darbepoetin-A and CERA might possibly cause more patients to overshoot the target level of Hb.
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Affiliation(s)
- Stavroula Ziakka
- Nephrology Clinic, Hellenic Red Cross Hospital Korgialeneio-Benakeio, Athens, Greece
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Locatelli F, Del Vecchio L. Erythropoietic response to erythropoiesis-stimulating agents and outcome: should we give up the haemoglobin target approach? Nephrol Dial Transplant 2011; 26:2069-71. [PMID: 21543657 DOI: 10.1093/ndt/gfr194] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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