Increased use of
erythropoiesis-stimulating agents and intravenous iron
treatment was associated with a decreased risk for mortality in patients on
dialysis with lower hematocrit levels.
However, in those patients with higher hematocrit levels, and therefore
a lower overall risk for mortality, increased use of ESAs and IV iron was
associated with an increased mortality risk.
To determine the optimal management of anemia in patients with end-stage
renal disease, researchers compared the one-year mortality risk associated with
different dialysis center–level patterns of ESA and IV iron use for
269,717 hemodialysis patients. The researchers pooled data from the Medicare
end-stage renal disease program between 1999 and 2007.
Patients with hematocrit levels less than 30% had the highest monthly
mortality rate (2.1%), whereas those with a hematocrit level of at least 36%
had the lowest monthly mortality rate (0.7%).
The use of a larger dose of ESAs in patients with the lowest hematocrit
levels (<30%) was associated with lower mortality rates compared with
centers that used smaller doses (HR=0.94; 95% CI, 0.9-0.97). Yet, centers that
used increased doses of ESAs among patients with hematocrit levels between 33%
and 35.9% (HR=1.07; 95% CI, 1.03-1.12) and hematocrit levels of at least 36%
(HR=1.11; 95% CI, 1.07-1.15) had higher mortality rates.
This pattern was similar when the researchers looked at the frequency of
IV iron use.
In centers that used IV iron more frequently, patients with a hematocrit
level less than 30% (HR=0.97; 95% CI, 0.94-0.99) and those with a hematocrit
level between 30% and 32.9% (HR=0.95; 95% CI, 0.91-0.98) had decreased
mortality rates, whereas more frequent IV iron use in patients with a
hematocrit level of at least 36% had increasing mortality rates (HR=1.07; 95%
CI, 1.02-1.13).
“Further observational and experimental studies are needed to help
identify optimal treatment algorithms for both ESAs and iron that maximize
clinical benefit while minimizing adverse outcomes,” the researchers
concluded.
Brookhart MA. JAMA. 2010;303:857-864.
Although it will be attempted, extrapolation of these data to chemotherapy-associated anemia treatment guidelines will be unfortunate. Dialysis patients have different thrombophilic propensities (eg, microparticle production from extracorporeal trauma, leukocyte activation, hypertension, etc.). The shoals of "evidence-based medicine" are exemplified by such likely apples/oranges extrapolation.
- Harry S. Jacob, MD
HemOnc Today Chief Medical Editor
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