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Study Examines Outcomes of Anaemia Management With ESAs in Haemodialysis Patients CHICAGO -- March 2, 2010 -- Greater use of erythropoiesis-stimulating agents (ESAs) and more frequent use of iron at lower hematocrit levels was associated with a decreased risk of death for patients on haemodialysis, according to a study published in the March 3 issue of JAMA. “Appropriate use of ESAs and intravenous iron can effectively manage the anaemia of chronic kidney disease and end-stage renal disease (ESRD), but several randomised trials have reported an increased risk of mortality and cardiovascular events in patients treated to achieve higher hematocrit levels,” the authors wrote. “The earlier of these reports prompted the US Food and Drug Administration in March 2007 to issue a black box warning for all ESAs recommending that they be used at the lowest level necessary to prevent transfusions. There is disagreement regarding the appropriate management of anemia in ESRD. M. Alan Brookhart, PhD, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, and colleagues assessed the 1-year mortality risk associated with different dialysis center-level patterns of ESA and intravenous iron use for 269,717 new haemodialysis patients. Using data from Medicare’s ESRD program (1999-2007), the researchers characterised each US dialysis centre’s annual anaemia management practice by estimating its typical use of ESAs and intravenous iron in haemodialysis patients within 4 hematocrit categories. After adjustment for various factors, the researchers found that certain patterns of ESA and iron use by dialysis centres were associated with different mortality risks among new patients at those centres. Centres that used larger doses of ESAs in patients with hematocrit <30% achieved lower mortality rates, while mortality rates were increased in centres that used larger ESA doses in patients with hematocrit between 33% and 35.9%, and in those with hematocrit of >=36%. “We observed decreased mortality in centres that used iron more frequently in patients with hematocrit less than 30% and in patients with hematocrit between 30% and 32.9%. We also observed increasing mortality rates in centres that used iron more frequently in patients with hematocrit levels of 36% or higher,” the authors wrote. “Further observational and experimental studies are needed to help identify optimal treatment algorithms for both ESAs and iron that maximise clinical benefit while minimising adverse outcomes.” SOURCE: JAMA E-mail this page to a friend or colleague! To print, use this version