title: Erythropoietin, folic acid deficiency and hyperhomocysteinemia: is there a possible relationship in chronically hemodialyzed patients?
abstract: OBJECTIVE
  To examine the possible relationships between recombinant human erythropoietin (rhEPO) therapy, serum folic acid and homocysteine levels in a cohort of stable, chronically hemodialyzed patients.
  
  
  METHODS
  The study was cross-sectional in its first phase and consisted of 3 groups of subjects (group 1:6 healthy controls; group 2:7 dialyzed patients not receiving rhEPO; group 3: 14 patients on rhEPO therapy). Hematological and biochemical parameters were taken after an overnight fast in all subjects. The second phase of the study was prospective, and included 8 dialyzed patients, and investigated the effects of a 6-month period of folic acid supplementation (10 mg, 3 times a week) on the same parameters examined in the first phase of the study.
  
  
  RESULTS
  In the first part of the study hemoglobin levels were near-normal, or normal, in all patients. No differences in hemoglobin or hematocrit values were observed in the 3 groups. 80% of all hemodialyzed patients had low serum folic acid levels, irrespective of whether they were receiving rhEPO. Serum erythropoietin level was elevated in group 3 (23.3+/-10.4 mIU/ml). In group 2, serum erythropoietin level was not different from that of the healthy controls (13.5+/-11.2 vs. 8.0+/-5.4 mIU/ml, p = n.s.). Total serum homocysteine levels were elevated in all dialyzed patients (group 2: 24.7+/-9.2 micromol/l; group 3: 31.6+/-14.4 micromol/l), with a significant difference seen when comparing controls and those dialyzed patients on rhEPO therapy (8.7+/-2.2 vs. 31.6+/-14.4 micromol/l; p<0.05). Significant correlations (ANOVA) were observed between serum erythropoietin and folic acid levels (r = -0.382; p = 0.049), and between folic acid and homocysteine levels (r = -0.560; p = 0.002). In the second part of the study folic acid supplementation led to a highly significant reduction in homocysteine levels (20.9+/-4.9 vs. 11.9+/-2.5 micromol/l; p<0.0005). Two of 3 patients receiving rhEPO therapy, had rhEPO discontinued after commencing folic acid, as hemoglobin levels remained adequate, even without rhEPO.
  
  
  CONCLUSIONS
  In hemodialyzed patients, the presence of a near-normal hemoglobin level, irrespective of rhEPO therapy, implies efficient erythropoiesis. Without adequate folic acid reserves, folic acid deficiency may develop in these patients and this will aggravate already high homocysteine levels. Therefore, folic acid supplementation is warranted in hemodialyzed patients, especially in those patients with hemoglobin levels approaching normal. This treatment is safe and effective in reducing homocysteine levels, especially when given in high doses for prolonged periods of time.
authors.affiliation: Department of Nephrology, Rabin Medical Center, Golda Campus, Petah Tikva, Israel.
authors.forename: A
authors.initials: A
authors.lastname: Korzets
authors.forename: Y
authors.initials: Y
authors.lastname: Ori
authors.forename: A
authors.initials: A
authors.lastname: Chagnac
authors.forename: T
authors.initials: T
authors.lastname: Weinstein
authors.forename: M
authors.initials: M
authors.lastname: Herman
authors.forename: D
authors.initials: D
authors.lastname: Zevin
authors.forename: T
authors.initials: T
authors.lastname: Malachi
authors.forename: U
authors.initials: U
authors.lastname: Gafter
mesh_terms: D000704:Analysis of Variance; D016022:Case-Control Studies; D003430:Cross-Sectional Studies; D004921:Erythropoietin / Q000097:blood / Q000627:therapeutic use*; D005260:Female; D005492:Folic Acid / Q000097:blood / Q000627:therapeutic use*; D005494:Folic Acid Deficiency / Q000097:blood* / Q000628:therapy; D006801:Humans; D020138:Hyperhomocysteinemia / Q000097:blood / Q000209:etiology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011994:Recombinant Proteins; D006435:Renal Dialysis
chemical_list: D011994:Recombinant Proteins; D004921:Erythropoietin; D005492:Folic Acid