title: Erythropoeitin dose variation in different facilities in different countries and its relationship to drug resistance.
abstract: BACKGROUND
  The correction of anemia using erythropoeitin (EPO) is accorded high priority in the management of patients undergoing hemodialysis (HD). Target hemoglobin (Hb) levels have been established in many countries. Following an observation that the mean facility EPO dose in a chain of facilities in the United States varied by more than two-fold, an examination of the practice of anemia correction in other settings was carried out.
  
  
  METHODS
  We reviewed demographic and laboratory parameters in prevalent HD patients in 50 United States facilities and in a single HD facility in Vicenza, Italy. The mean EPO dose profile of the United States facilities was compared with the profiles in 10 facilities in the eastern United Kingdom (UKER) and in 20 facilities reporting to the United Kingdom Renal Registry (UKRR). Analysis of the factors that correlate with EPO resistance was carried out using the United States and Italian data.
  
  
  RESULTS
  The average EPO doses, by facility, in the 51 United States, the 10 UKER, and the 19 UKRR facilities were 19,569, 8,416, and 7,992 international units per week (IU/wk), respectively. While examination of the UKRR revealed a similar degree of inter-facility variation (2.6-fold), much larger doses of EPO were being administered in the United States patients, particularly in the low Hb group. Multivariate analysis of the United States data suggested that factors related to inflammation, including low albumin, the use of tunneled catheters for vascular access, and low protein catabolic rate (enPCR) correlated with low Hb and relative EPO resistance.
  
  
  CONCLUSIONS
  Despite similar guidelines for anemia management, significant differences in practice are observed. While there seems to be a reluctance to administer large EPO doses to individual patients in Europe, this does not seem to apply in the United States, where more EPO is given. EPO resistance seems relative rather than absolute in many patients, allowing some to respond to the higher doses.
authors.affiliation: Lister Renal Unit, Stevenage, United Kingdom.
authors.forename: Roger N
authors.initials: RN
authors.lastname: Greenwood
authors.forename: Claudio
authors.initials: C
authors.lastname: Ronco
authors.forename: Fiorella
authors.initials: F
authors.lastname: Gastaldon
authors.forename: Alessandra
authors.initials: A
authors.lastname: Brendolan
authors.forename: Peter
authors.initials: P
authors.lastname: Homel
authors.forename: Len
authors.initials: L
authors.lastname: Usvyat
authors.forename: Lenore
authors.initials: L
authors.lastname: Bruno
authors.forename: Mary
authors.initials: M
authors.lastname: Carter
authors.forename: Nathan W
authors.initials: NW
authors.lastname: Levin
mesh_terms: D000368:Aged; D000740:Anemia / Q000188:drug therapy* / Q000209:etiology; D004351:Drug Resistance; D004921:Erythropoietin / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D007558:Italy; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D012044:Regression Analysis; D006435:Renal Dialysis; D006113:United Kingdom; D014481:United States
chemical_list: D004921:Erythropoietin