Mortality in dialysis patients may not be associated with ESA dose: a 2-year prospective observational study.
BACKGROUND
Anaemia of chronic kidney disease increases the risk of death and adverse events, but can be managed using erythropoiesis stimulating agents (ESAs). However, recent evidence suggests that targeting a higher haemoglobin concentration ([Hb]) increases mortality risk, and both higher [Hb] targets and ESA doses have been implicated. Nonetheless, a causative role has not been demonstrated, and this potential relationship requires further appraisal in such a complex patient group.


METHODS
The relationship between the haematopoietic response to ESAs and patient survival in 302 stable, prevalent dialysis patients was explored in a prospective, single-centre study. Clinical and laboratory parameters influencing mortality and ESA resistance were analysed. Patients were stratified into 5 groups, according to their [Hb] and ESA dosage, and were followed for 2 years.


RESULTS
Little difference in co-morbidities between groups was identified. 73 patients died and 36 were transplanted. Initial analysis suggested a direct relationship between mortality and ESA dosage. However, Cox proportional hazards multivariate analysis demonstrated mortality risk was associated only with age (adjusted HR per year: 1.061, 95% CI 1.031-1.092), dialysis duration (adjusted HR: 1.010, 95% CI 1.004-1.016), peripheral vascular disease (adjusted HR: 1.967, 95% CI 1.083-3.576) and CRP (adjusted HR: 1.024, 95% CI 1.011-1.039). Mortality was increased in patients poorly responsive to ESAs (55.5%).


CONCLUSIONS
ESA dose does not appear to contribute substantially to mortality risk in dialysis patients. Instead, age and co-morbidities appear to be the critical determinants. A poor response to ESAs is a marker of overall poor health status.
Monash University, Melbourne, Australia. lawrence.mcmahon@monash.edu
Lawrence P
LP
McMahon
Michael X
MX
Cai
Sanjeev
S
Baweja
Stephen G
SG
Holt
Annette B
AB
Kent
Vlado
V
Perkovic
Murray J
MJ
Leikis
Gavin J
GJ
Becker
D000368:Aged; D000740:Anemia / Q000401:mortality* / Q000517:prevention & control*; D001315:Australia / Q000453:epidemiology; D015897:Comorbidity; D004305:Dose-Response Relationship, Drug; D005260:Female; D006397:Hematinics / Q000008:administration & dosage*; D006801:Humans; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000401:mortality*; D051436:Renal Insufficiency, Chronic / Q000401:mortality* / Q000534:rehabilitation*; D012307:Risk Factors; D016019:Survival Analysis; D015996:Survival Rate; D016896:Treatment Outcome
D006397:Hematinics