1
|
Macdougall IC. Anaemia in CKD-treatment standard. Nephrol Dial Transplant 2024; 39:770-777. [PMID: 38012124 DOI: 10.1093/ndt/gfad250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Indexed: 11/29/2023] Open
Abstract
Anaemia is one of the most common complications of chronic kidney disease (CKD), having a significant impact on quality of life, and is also associated with a number of adverse clinical outcomes. Its pathogenesis is multifactorial, caused largely by an inadequate production of erythropoietin from the diseased kidneys, with iron deficiency, inflammation, shortened red cell lifespan and enhanced blood loss also being contributory factors. The management of this condition was transformed in the late 1980s by the advent of recombinant human erythropoietin (epoetin), and treatment paradigms have developed over the last three decades, largely focusing on a combination of epoetin or its analogues (erythropoiesis-stimulating agents; ESAs) along with iron supplementation, often administered intravenously due to increased hepcidin levels limiting iron absorption from the gut. Indeed, in patients with early CKD and iron deficiency, iron per se may be sufficient to improve the anaemia, delaying the need for ESA therapy. Other causes of anaemia should be excluded and corrected (if possible) before resorting to treatment with ESAs and iron. More recently, the hypoxia-inducible factor-prolyl hydroxylase inhibitors have entered the therapeutic arena; these are orally active agents that upregulate endogenous erythropoietin production as well as a number of iron-regulatory genes which may also enhance erythropoiesis. The latter drugs are highly efficacious, and may have advantages in inflammatory conditions causing resistance to conventional ESA therapy, but concerns exist regarding their safety, particularly in the longer term. This article reviews the current standards of treatment, as well as recent novel developments in the management of anaemia in CKD.
Collapse
|
2
|
Chiang WF, Hsiao PJ, Wu KL, Chen HM, Chu CM, Chan JS. Investigation of the Relationship between Lean Muscle Mass and Erythropoietin Resistance in Maintenance Haemodialysis Patients: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19095704. [PMID: 35565102 PMCID: PMC9100199 DOI: 10.3390/ijerph19095704] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 12/04/2022]
Abstract
Each patient undergoing maintenance haemodialysis (MHD) has a different response to erythropoiesis-stimulating agents (ESAs). Haemodilution due to fluid overload has been shown to contribute to anaemia. Body mass index (BMI) has been shown to influence ESA response in dialysis patients; however, BMI calculation does not distinguish between fat and lean tissue. The association between lean muscle mass and erythropoietin hyporesponsiveness is still not well-known among MHD patients. We designed a cross-sectional study and used bioimpedance spectroscopy (BIS) to analyse the relationship between body composition, haemoglobin level, and erythropoietin resistance index (ERI) in MHD patients. Seventy-seven patients were enrolled in the study group. Compared with patients with haemoglobin ≥ 10 g/dL, those with haemoglobin < 10 g/dL had higher serum ferritin levels, malnutrition−inflammation scores (MIS), relative overhydration, ESA doses, and ERIs. In multivariate logistic regression, higher ferritin levels and MIS were the only predictors of lower haemoglobin levels. The ERI was significantly positively correlated with age, Kt/V, ferritin levels, and MIS and negatively correlated with albumin levels, BMI, and lean tissue index (LTI). Multivariate linear regression analysis revealed that ferritin levels, BMI, and LTI were the most important predictors of ERI. In MHD patients, using BIS to measure body composition can facilitate the development of early interventions that aim to prevent sarcopenia, support ESA responsiveness, and, consequently, improve anaemia management.
Collapse
Affiliation(s)
- Wen-Fang Chiang
- Division of Nephrology, Department of Medicine, Armed Forces Taoyuan General Hospital, Taoyuan 325, Taiwan; (W.-F.C.); (K.-L.W.)
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
- School of Medicine, National Defense Medical Center, Taipei 114, Taiwan
| | - Po-Jen Hsiao
- Division of Nephrology, Department of Medicine, Armed Forces Taoyuan General Hospital, Taoyuan 325, Taiwan; (W.-F.C.); (K.-L.W.)
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
- School of Medicine, National Defense Medical Center, Taipei 114, Taiwan
- Department of Life Sciences, National Central University, Taoyuan 320, Taiwan
- Division of Nephrology, Department of Medicine, Fu-Jen Catholic University Hospital, School of Medicine, Fu-Jen Catholic University, New Taipei City 242, Taiwan
- Correspondence: or (P.-J.H.); (J.-S.C.); Tel.: +886-3-4799595 (ext. 325823) (P.-J.H. & J.-S.C.)
| | - Kun-Lin Wu
- Division of Nephrology, Department of Medicine, Armed Forces Taoyuan General Hospital, Taoyuan 325, Taiwan; (W.-F.C.); (K.-L.W.)
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
- School of Medicine, National Defense Medical Center, Taipei 114, Taiwan
| | - Hung-Ming Chen
- Division of Haematology and Oncology, Department of Medicine, Armed Forces Taoyuan General Hospital, Taoyuan 325, Taiwan;
| | - Chi-Ming Chu
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei 114, Taiwan;
- School of Public Health, National Defense Medical Center, Taipei 114, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei 114, Taiwan
- Department of Public Health, School of Public Health, China Medical University, Taichung 404, Taiwan
- Department of Public Health, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Big Data Research Center, Fu-Jen Catholic University, New Taipei City 242, Taiwan
- Division of Biostatistics and Medical Informatics, Department of Epidemiology, School of Public Health, National Defense Medical Center, Taipei 114, Taiwan
| | - Jenq-Shyong Chan
- Division of Nephrology, Department of Medicine, Armed Forces Taoyuan General Hospital, Taoyuan 325, Taiwan; (W.-F.C.); (K.-L.W.)
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
- School of Medicine, National Defense Medical Center, Taipei 114, Taiwan
- Correspondence: or (P.-J.H.); (J.-S.C.); Tel.: +886-3-4799595 (ext. 325823) (P.-J.H. & J.-S.C.)
| |
Collapse
|
3
|
Ueda E, Fujikawa T, Toya Y, Kuji T, Kakimoto-Shino M, Kawai Y, Kawano T, Azushima K, Wakui H, Tamura K. Clinical significance of a novel reticulocyte-based erythropoietin resistance index in HD patients: A retrospective study. Ther Apher Dial 2021; 26:915-923. [PMID: 34863017 DOI: 10.1111/1744-9987.13772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The erythropoietin resistance index (ERI) is an indicator of erythropoiesis-stimulating agent (ESA) responsiveness and is typically calculated using Hb. However, Hb does not directly reflect ESA-induced erythropoiesis because of its long-term nature. We thus designed a novel ERI calculated with reticulocyte Hb (RetHb), a real-time index, and investigated its association with mortality in HD patients. METHODS We calculated the ERI using the change in RetHb before and after ESA administration (ERIΔRetHb ) and retrospectively analyzed its association with 3-year all-cause mortality using Kaplan-Meier survival curves and Cox regression analyses. RESULTS A total of 102 patients were included. Patients with the highest ERIΔRetHb had the worst prognosis according to the Kaplan-Meier survival curves (Log-rank p = 0.02). Multivariate Cox regression analysis showed that the ERIΔRetHb was significantly and independently associated with all-cause mortality (hazard ratio: 9.82, 95% CI [1.50, 64.41], p = 0.02). CONCLUSION The ERIΔRetHb was significantly and independently associated with all-cause mortality in HD patients.
Collapse
Affiliation(s)
- Eiko Ueda
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,Department of Medicine, Yokohama City University Medical Center, Yokohama, Japan
| | - Tetsuya Fujikawa
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,Center for Health Service Sciences, Yokohama National University, Yokohama, Japan
| | - Yoshiyuki Toya
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Tadashi Kuji
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,Yokodai Central Clinic, Yokohama, Japan
| | - Midori Kakimoto-Shino
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yuki Kawai
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,Department of Medicine, Yokohama City University Medical Center, Yokohama, Japan
| | | | - Kengo Azushima
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hiromichi Wakui
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| |
Collapse
|
4
|
Effects of blood urea nitrogen independent of the estimated glomerular filtration rate on the development of anemia in non-dialysis chronic kidney disease: The results of the KNOW-CKD study. PLoS One 2021; 16:e0257305. [PMID: 34506574 PMCID: PMC8432877 DOI: 10.1371/journal.pone.0257305] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 08/27/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Anemia is a common complication of chronic kidney disease (CKD). Blood urea nitrogen (BUN) in CKD represents nitrogenous uremic toxin accumulation which could be involved in anemia of CKD. We investigated the effects of BUN independent of estimated glomerular filtration rate (eGFR) on anemia in non-dialysis CKD (NDCKD). METHODS This prospective study included 2,196 subjects enrolled in the KoreaN Cohort Study for Outcome in Patients With Chronic Kidney Disease (KNOW-CKD) cohort with BUN and hemoglobin level data. Initially, we investigated the association between BUN and hemoglobin level. To examine the impact of baseline BUN on the incident anemia, a longitudinal study was performed on 1,169 patients without anemia at study enrollment. BUN residuals were obtained from the fitted curve between BUN and eGFR. Anemia was defined as a hemoglobin level of <13.0 g/dL for men and <12.0 g/dL for women. RESULTS BUN residuals were not related to eGFR but to daily protein intake (DPI), while BUN was related to both eGFR and DPI. BUN was inversely associated with hemoglobin level (β -0.03; 95% confidence interval [CI] -0.04, -0.03; P <0.001) in the multivariable linear regression analysis adjusted for multiple confounders including eGFR, and BUN residual used instead of BUN was also inversely associated with hemoglobin level (β -0.03; 95% CI -0.04, -0.02; P <0.001). Among the 1,169 subjects without anemia at baseline, 414 (35.4%) subjects newly developed anemia during the follow-up period of 37.5 ± 22.1 months. In the multivariable Cox regression analysis with adjustment, both high BUN level (Hazard ratio [HR] 1.02; 95% CI 1.01, 1.04; P = 0.002) and BUN residual used instead of BUN (HR 1.02; 95% CI 1.00, 1.04; P = 0.031) increased the risk of anemia development. Moreover, BUN, rather than eGFR, increased the risk of anemia development in patients with CKD stage 3 in the multivariable Cox regression. CONCLUSION Higher BUN levels derived from inappropriately high protein intake relative to renal function were associated with low hemoglobin levels and the increased risk of anemia independent of eGFR in NDCKD patients.
Collapse
|
5
|
The Influence of Inflammation on Anemia in CKD Patients. Int J Mol Sci 2020; 21:ijms21030725. [PMID: 31979104 PMCID: PMC7036805 DOI: 10.3390/ijms21030725] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/15/2020] [Accepted: 01/19/2020] [Indexed: 02/06/2023] Open
Abstract
Anemia is frequently observed in the course of chronic kidney disease (CKD) and it is associated with diminishing the quality of a patient’s life. It also enhances morbidity and mortality and hastens the CKD progression rate. Patients with CKD frequently suffer from a chronic inflammatory state which is related to a vast range of underlying factors. The results of studies have demonstrated that persistent inflammation may contribute to the variability in Hb levels and hyporesponsiveness to erythropoietin stimulating agents (ESA), which are frequently observed in CKD patients. The understanding of the impact of inflammatory cytokines on erythropoietin production and hepcidin synthesis will enable one to unravel the net of interactions of multiple factors involved in the pathogenesis of the anemia of chronic disease. It seems that anti-cytokine and anti-oxidative treatment strategies may be the future of pharmacological interventions aiming at the treatment of inflammation-associated hyporesponsiveness to ESA. The discovery of new therapeutic approaches towards the treatment of anemia in CKD patients has become highly awaited. The treatment of anemia with erythropoietin (EPO) was associated with great benefits for some patients but not all.
Collapse
|
6
|
Matos JF, Peralta R, Felix C, Pinto B, Goncalves P, Carlos V, Rodrigues R, Parisotto MT, Carvalho MJ, Ponce P. Restitution volumes at the end of dialysis sessions: A potential influencing factor on patients' haemoglobin levels? Nurs Open 2019; 6:1307-1313. [PMID: 31660157 PMCID: PMC6805275 DOI: 10.1002/nop2.322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 05/01/2019] [Accepted: 05/13/2019] [Indexed: 11/16/2022] Open
Abstract
AIM To evaluate whether haemoglobin (Hb) levels are influenced by the restitution volume (RestVol) at the end of the dialysis session, independently of erythropoiesis-stimulating agents (ESA) and iron doses. DESIGN Over 12 months, 4,386 haemodialysis patients from 34 centres were enrolled in this observational descriptive study according to the checklist STrengthening the Reporting of Observational Studies in Epidemiology (STROBE). METHOD RestVol, Hb levels, ESA and iron doses of every patient were assessed on a monthly basis. To determine the ideal RestVol, the clinics were classified into three groups according to the restitution volumes at the end of the dialysis sessions. RESULTS Mean age was 69 ± 14 years, and 58.9% were men. The evaluation of 665,712 treatments revealed that RestVol of 380 ml seems to be the most efficient, since the clinics in this group managed to reduce ESA consumption with a negligible reduction in Hb levels.
Collapse
Affiliation(s)
| | - Ricardo Peralta
- NephroCare PortugalFresenius Medical Care PortugalPortoPortugal
| | - Carla Felix
- NephroCare PortugalFresenius Medical Care PortugalPortoPortugal
| | - Bruno Pinto
- NephroCare PortugalFresenius Medical Care PortugalPortoPortugal
| | - Pedro Goncalves
- NephroCare PortugalFresenius Medical Care PortugalPortoPortugal
| | - Vera Carlos
- NECE‐UBIUniversidade da Beira InteriorCovilhãPortugal
- EMAESUniversidade da Beira InteriorCovilhãPortugal
- Universidade de AveiroAveiroPortugal
| | - Ricardo Rodrigues
- NECE‐UBIUniversidade da Beira InteriorCovilhãPortugal
- EMAESUniversidade da Beira InteriorCovilhãPortugal
| | | | | | - Pedro Ponce
- NephroCare PortugalFresenius Medical Care PortugalLisboaPortugal
| |
Collapse
|
7
|
Rosati A, Ravaglia F, Panichi V. Improving Erythropoiesis Stimulating Agent Hyporesponsiveness in Hemodialysis Patients: The Role of Hepcidin and Hemodiafiltration Online. Blood Purif 2018; 45:139-146. [PMID: 30959500 DOI: 10.1159/000485314] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 11/14/2017] [Indexed: 12/23/2022]
Abstract
Hyporesponsiveness to erythropoietin stimulating agents (ESAs) is a condition associated with increased mortality. Even after identifying the condition, the causes are difficult to treat and only partially reversible in end-stage renal disease patients. Thus, the role of more recent hemodialysis (HD) techniques in improving such conditions is an emerging issue. However, major randomized clinical trials have not confirmed the results of smaller observational studies in which online hemodiafiltration has shown some efficacy in improving patients' response to ESAs. In our interpretation, these findings are not in contrast, but they can be explained by a better understanding of the interactions between HD and ESAs on iron mobilization, first of all through the role of hepcidin. The kinetics of hepcidin removal through HD combined with the action of selected ESAs may help the clinician in prescribing the best association between HD treatment and ESAs to overcome hyporesponsiveness.
Collapse
Affiliation(s)
- Alberto Rosati
- Nephrology Unit, Nuovo San Giovanni di Dio Hospital, Florence, Italy,
| | | | | |
Collapse
|
8
|
Stević N, Stefanović N, Veličković - Radovanović R, Apostolović B, Paunović K, Cvetković M, Virijević D, Cvetković T. T HE INFLUENCE OF ACE INHIBITORS TREATMENT ON ANEMIA PARAMETERS IN PATIENTS ON MAINTENANCE HEMODIALYSIS. ACTA MEDICA MEDIANAE 2017. [DOI: 10.5633/amm.2017.0317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
9
|
Tomanoski V, Gjorgjievska G, Zvezdakovska J, Krecova V, Andonoski A, Nakovska M, Muharemi S, Kliseski T, Janakievska P, Ristoska K, Veliu R, Vasileva L, Jovanov T, Mehmedi-Veseli K, Ferati B, Sterjovska J, Kepeska S, Kachakova A. The Determinants of Hemoglobin Variability in Hemodialysis Patients. BANTAO JOURNAL 2017. [DOI: 10.1515/bj-2016-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Introduction. Factors that have been reported to affect erythropoietin (EPO) responsiveness in hemodialysis (HD) patients include iron deficiency, chronic inflammation, secondary hyperparathyroidism, malnutrition and inadequate HD dose. The aim of the study was to analyze the deteminants of hemoglobin variability in HD patients. Methods. The study encompassed 526 patients (197 F and 329 M). According to HD vintage at the beginning of the study the patients were divided into two groups: group-1 encompassed 153 patients with HD vintage bellow 24 months, and group-2 encompassed 329 patients with HD vintage over 24 months. Over a period of 21 months after admission the following parameters were analyzed: hemoglobin (Hb), EPO dose, iron dose, HD dose (eKT/V), transferrin saturation (TSAT), C-reactive protein (CRP), ferritin and serum albumin at 3 months and parathyroid hormone (PTH) at 6 months. Results. The percentage of patients with Hb>=105g/L significantly improved, and the average Hb level significantly increased in both groups over a period of 21 months. The average EPO and iron dose significantly decreased, but TSAT and ferritin levels significantly increased over a period of 21 months. The average eKT/V and s-albumin values significantly increased, but the average CRP and PTH levels significantly decresead over a period of 21 months. In group-1 EPO dose and CRP, but in group-2 EPO dose, ferritin, HD vintage, and iron dose were statistically significant predictors of the Hb level 9 months after admission. Conclusions. Insufficient EPO therapy, iron deficiency and chronic inflammation were the main factors of inadequate correction of anemia in HD patients before admission.
Collapse
Affiliation(s)
| | | | | | - Vasiliki Krecova
- Sistina Nefroplus Centers of Hemodialysis, Skopje , Republic of Macedonia
| | | | - Margarita Nakovska
- Sistina Nefroplus Centers of Hemodialysis, Skopje , Republic of Macedonia
| | - Serjat Muharemi
- Sistina Nefroplus Centers of Hemodialysis, Skopje , Republic of Macedonia
| | - Tode Kliseski
- Sistina Nefroplus Centers of Hemodialysis, Skopje , Republic of Macedonia
| | | | - Katerina Ristoska
- Sistina Nefroplus Centers of Hemodialysis, Skopje , Republic of Macedonia
| | - Ramazan Veliu
- Sistina Nefroplus Centers of Hemodialysis, Skopje , Republic of Macedonia
| | - Liljana Vasileva
- Sistina Nefroplus Centers of Hemodialysis, Skopje , Republic of Macedonia
| | - Toni Jovanov
- Sistina Nefroplus Centers of Hemodialysis, Skopje , Republic of Macedonia
| | | | - Beane Ferati
- Sistina Nefroplus Centers of Hemodialysis, Skopje , Republic of Macedonia
| | - Jasmina Sterjovska
- Sistina Nefroplus Centers of Hemodialysis, Skopje , Republic of Macedonia
| | - Sintia Kepeska
- Sistina Nefroplus Centers of Hemodialysis, Skopje , Republic of Macedonia
| | - Angela Kachakova
- Sistina Nefroplus Centers of Hemodialysis, Skopje , Republic of Macedonia
| |
Collapse
|
10
|
Petrulienė K, Žiginskienė E, Kuzminskis V, Nedzelskienė I, Bumblytė IA. Hepcidin serum levels and resistance to recombinant human erythropoietin therapy in hemodialysis patients. MEDICINA-LITHUANIA 2017; 53:90-100. [PMID: 28416170 DOI: 10.1016/j.medici.2017.03.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 11/25/2016] [Accepted: 03/20/2017] [Indexed: 02/09/2023]
Abstract
OBJECTIVE The aim of this study was to analyze the factors that are associated with the response to erythropoiesis-stimulating agents (ESAs) and its association with hospitalization and mortality rates; to evaluate the serum hepcidin level and its associations with iron profile, inflammatory markers, ESA responsiveness, and mortality; and to determine independent factors affecting ERI and hepcidin. MATERIALS AND METHODS To evaluate a dose-response effect of ESAs we used the erythropoietin resistance index (ERI). Patients were stratified in two groups: nonresponders and responders (ERI>15, n=20, and ERI ≤15U/kg/week/g per 100mL, n=153, respectively). Hematological data, hepcidin levels, iron parameters, inflammatory markers, hospitalization and mortality rates were compared between the groups. Multiple regression analysis was used to determine independent factors affecting ERI and hepcidin. RESULTS C-reactive protein (CRP) (β=0.078, P=0.007), albumin (β=-0.436, P=0.004), body mass index (β=-0.374, P<0.001), and hospitalization rate per year (β=3.017, P<0.001) were found to be significant determinants of ERI in maintenance hemodialysis (MHD) patients. Inadequate dialysis was associated with higher ERI. Patients with concomitant oncological diseases had higher ERI (31.2±12.4 vs 9.7±8.1U/kg/week/g per 100mL, P=0.002). The hepcidin level was 158.51±162.57 and 120.65±67.28ng/mL in nonresponders and responders, respectively (P=0.33). Hepcidin correlated directly with ERI, dose of ESAs, ferritin and inversely with Hb, transferrin saturation, and albumin. ERI (β=4.869, P=0.002) and ferritin (β=0.242, P=0.003) were found to be significant determinants of hepcidin in MHD patients. The hospitalization rate per year was 2.35±1.8 and 1.04±1.04 in nonresponders and responders, respectively (P=0.011). The mean length of one hospitalization was 25.12±21.26 and 10.82±17.25 days, respectively (P=0.012). Death occurred in 30% of the patients from the responders' group and in 50% from the nonresponders' group (P=0.289). The mean hepcidin concentration of patients who died was 141.9±129.62ng/mL and who survived, 132.98±109.27ng/mL (P=0.797). CONCLUSIONS CRP, albumin, BMI, and hospitalization rate per year were found to be significant determinants of ERI in MHD patients. Inadequate dialysis was associated with higher epoetin requirements. There were no difference in patient mortality by ERI, but a significant difference in hospitalization rates and mean length of one hospitalization was revealed. A significant positive relation between hepcidin and ERI was revealed. ERI and ferritin were found to be significant determinants of hepcidin in MHD patients. Hepcidin was not related to mortality.
Collapse
Affiliation(s)
- Kristina Petrulienė
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | - Edita Žiginskienė
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vytautas Kuzminskis
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Irena Nedzelskienė
- Department of Odontology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Inga Arūnė Bumblytė
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| |
Collapse
|
11
|
Ryta A, Chmielewski M, Debska-Slizien A, Jagodzinski P, Sikorska-Wisniewska M, Lichodziejewska-Niemierko M. Impact of gender and dialysis adequacy on anaemia in peritoneal dialysis. Int Urol Nephrol 2017; 49:903-908. [PMID: 28058668 PMCID: PMC5403856 DOI: 10.1007/s11255-016-1499-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 12/27/2016] [Indexed: 12/19/2022]
Abstract
Purpose In the general population, haemoglobin (Hb) concentration is higher in men than in women. However, target Hb levels in dialysis patients are set constant regardless of the patient’s sex. The aim of this study was to evaluate Hb concentration and the use of erythropoiesis-stimulating agents (ESA) in peritoneal dialysis (PD) patients taking gender and dialysis adequacy into account. Methods The study comprised two parts. The first was a cross-sectional analysis of Hb and ESA in 2180 prevalent PD patients. The second included 88 incident PD patients, followed for 36 months. During this time, the major parameters recorded at 12-month intervals included: Hb concentration, weekly ESA, total, renal, and peritoneal Kt/V. Erythropoietin resistance index (ERI) was calculated as the ratio between ESA dose and achieved Hb. Results In prevalent PD patients, Hb concentration was significantly lower in women, (11.2 ± 1.4 vs. 11.5 ± 1.6 g/dl; p < 0.001), despite higher doses of ESA (2691 ± 1821 vs. 2344 ± 1422; p = 0.001). Hb concentrations were related to dialysis adequacy in both cohorts. However, despite significantly higher Kt/V, women were characterized by a lower Hb level. In incident patients, this association was present throughout the observation period, while the ESA dose in women was significantly higher at every time point. In multiple regression analysis, gender was an independent determinant of ERI (b = 0.34; p < 0.05). Conclusions Despite higher dialysis adequacy, Hb concentration in women treated with PD is significantly lower, and the ability to correct it impaired, as compared to men.
Collapse
Affiliation(s)
- Alicja Ryta
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland.,Department of Hygiene and Epidemiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Michal Chmielewski
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Alicja Debska-Slizien
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Piotr Jagodzinski
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | | | - Monika Lichodziejewska-Niemierko
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland. .,Department of Palliative Medicine, Medical University of Gdańsk, Gdańsk, Poland.
| |
Collapse
|
12
|
Thresholds of iron markers for iron deficiency erythropoiesis-finding of the Japanese nationwide dialysis registry. Kidney Int Suppl (2011) 2015; 5:23-32. [PMID: 26097782 PMCID: PMC4455189 DOI: 10.1038/kisup.2015.6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Reportedly, serum ferritin levels are much lower in Japanese hemodialysis (HD)
patients than their Western counterparts. Therefore, the cutoff values of
ferritin and transferrin saturation (TSAT) for iron deficiency might differ from
other countries. We conducted a cross-sectional observational study using the
Japanese nationwide registry data. We enrolled 142,339 maintenance HD patients
and assessed the association between these markers, hemoglobin (Hb), and
erythropoiesis-stimulating agent (ESA) resistance index (ERI) utilizing
restricted cubic spline analyses. Median ferritin and TSAT levels were 73 (IQR:
31–158) ng/ml and 23.7 (16.8–32.0)%, respectively.
These lower ferritin ranges may possibly stem from a lower inflammatory state in
Japanese patients, as shown in median CRP of 1.0 mg/l. An adjusted
nonlinear association between Hb and TSAT showed that Hb levels drop with the
decrease in TSAT below 20%, regardless of serum ferritin levels,
suggesting the absolute iron deficiency cutoff as 20% for TSAT. In
patients with TSAT >20%, the association between Hb and ferritin
levels is nearly flat, whereas in patients with TSAT <20%, ferritin
<50 ng/ml was associated with low Hb. In long-acting ESAs-users
with TSAT >20%, U-shaped relationship was observed between ERI and
ferritin with the bottom of ERI around 100 ng/ml of ferritin,
possibly because high ferritin levels reflected an inflamed state leading to
hyporesponsiveness to ESA. The patient subgroup with TSAT <20% and
ferritin >100 ng/ml had significantly higher ERIs compared with
the subgroup with TSAT >20% and ferritin <100 ng/ml,
implying that TSAT, rather than ferritin, should be a primary iron marker
predicting ESA response.
Collapse
|
13
|
Alves MT, Vilaça SS, Carvalho MDG, Fernandes AP, Dusse LMS, Gomes KB. Resistance of dialyzed patients to erythropoietin. Rev Bras Hematol Hemoter 2015; 37:190-7. [PMID: 26041422 PMCID: PMC4459468 DOI: 10.1016/j.bjhh.2015.02.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 11/24/2014] [Indexed: 02/07/2023] Open
Abstract
Resistance to recombinant human erythropoietin is a common condition in dialyzed patients with chronic kidney disease and is associated with more hospitalizations, increased mortality and frequent blood transfusions. The main cause of hyporesponsiveness to recombinant human erythropoietin in these patients is iron deficiency. However, a high proportion of patients does not respond to treatment, even to the use of intravenous iron, which indicates the presence of other important causes of resistance. In addition to the iron deficiency, the most common causes of resistance include inflammation, infection, malnutrition, inadequate dialysis, and hyperparathyroidism, although other factors may be associated. In the presence of adequate iron stores, other causes should be investigated and treated appropriately.
Collapse
Affiliation(s)
| | | | | | | | | | - Karina Braga Gomes
- Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil.
| |
Collapse
|
14
|
Alves MT, Vilaça SS, Godoi LC, Rezende Júnior L, Carvalho MDG, Silva FDS, Guimarães FL, Fernandes AP, Dusse LMS, Gomes KB. Parvovirus B19 (B19) and cytomegalovirus (CMV) infections and anti-erythropoietin (anti-EPO) antibodies in patients on dialysis hyporesponsive to erythropoietin therapy. Clin Chim Acta 2014; 431:52-7. [PMID: 24513539 DOI: 10.1016/j.cca.2014.01.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 01/28/2014] [Accepted: 01/29/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Approximately 10% of patients receiving recombinant human erythropoietin (rHuEPO) do not respond to the treatment. We evaluated parvovirus B19 (B19) and cytomegalovirus (CMV) infections and antierythropoietin (anti-EPO) antibodies as potential causes of anemia in dialyzed patients, hyporesponsive to rHuEPO. METHODS Data from 120 dialyzed patients, receiving rHuEPO alfa, were collected: demographic characteristics, rHuEPO dose, duration of rHuEPO treatment and time on dialysis, etiology of chronic kidney disease and transfusion history. Serology and PCR were performed to address B19 and CMV infection status. An ELISA was developed to detect anti-EPO antibodies. RESULTS rHuEPO resistance correlated with high ferritin levels (p = 0.001) and short time on dialysis (p = 0.012). B19 DNA was found in 10 (8.3%) dialyzed patients and CMV DNA was detected in 33 (27.5%). There was no significant correlation between B19 infection and anemia,while a tendency of correlation between active CMV infection and hemoglobin levels or hematocrit value (p= 0.069 and p= 0.070, respectively) has been observed. Anti-EPO antibodies were not detected in any patient. CONCLUSIONS B19 infection is a rare complication in dialyzed patients and should be investigated after exclusion of other common causes, while CMV infection is rather common. The role of CMV infection in the hyporesponsiveness in dialyzed patients should be further evaluated in other studies. Our data suggest that anti-EPO antibodies are not involved in rHuEPO resistance in this population.
Collapse
|
15
|
Ayesh Haj Yousef MH, Bataineh A, Elamin E, Khader Y, Alawneh K, Rababah M. Adequate hemodialysis improves anemia by enhancing glucose-6-phosphate dehydrogenase activity in patients with end-stage renal disease. BMC Nephrol 2014; 15:155. [PMID: 25261071 PMCID: PMC4181374 DOI: 10.1186/1471-2369-15-155] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 09/23/2014] [Indexed: 11/10/2022] Open
Abstract
Background We conducted this study to determine the erythrocyte glucose-6-phosphate dehydrogenase (G6PD) activity level in patients with end-stage renal disease (ESRD) on maintenance hemodialysis (HD) and to determine the effect of hemodialysis adequacy on G6PD activity levels and its impact on anemia. Methods Eighty-two patients (48 men and 34 women) receiving regular hemodialysis for ESRD through arteriovenous fistulae for at least one year prior to the start of the study were enrolled in this study. G6PD activity levels were measured in all patients and the average Kt/V was used as a parameter of HD adequacy. Patients were divided into two groups according to Kt/V values. Group 1 included 45 patients with Kt/V˃1.2 (adequate HD), and group 2 included 37 patients with Kt/V˃1.2 (inadequate HD). The average hemoglobin level and the weekly dose of an erythropoietin-stimulating agent, epoetin alpha (ESA), for each patient were calculated for one year. Results The mean (SD) erythrocyte G6PD activity for all patients on hemodialysis was 7.64 ± 1.85 U/g Hb. Patients who had received adequate hemodialysis had a significantly higher average erythrocyte G6PD (mean (SD) = 9.2 ± 0.7 U/g Hb) compared to patients who had inadequate hemodialysis (mean (SD) = 5.7 ± 0.7U/g Hb) (P-value <0.005). The mean hemoglobin concentration was significantly higher in patients with adequate hemodialysis compared to those with inadequate hemodialysis. Conclusion Our study demonstrated the beneficial effect of adequate hemodialysis in correcting anemia by enhancing the erythrocyte G6PD activity in patients.
Collapse
Affiliation(s)
- Mahmoud Husni Ayesh Haj Yousef
- Department of Internal Medicine, King Abdullah University Hospital, Faculty of Medicine, Jordan University of Science and Technology, P,O, Box 3030, Irbid 22110, Jordan.
| | | | | | | | | | | |
Collapse
|
16
|
He L, Fu M, Chen X, Liu H, Chen X, Peng X, Liu F, Peng Y. Effect of dialysis dose and membrane flux on hemoglobin cycling in hemodialysis patients. Hemodial Int 2014; 19:263-9. [PMID: 25215434 DOI: 10.1111/hdi.12215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Many studies found that hemoglobin (Hb) fluctuation was closely related to the prognosis of the maintenance hemodialysis patients. We investigated the association of factors relating dialysis dose and dialyzer membrane with Hb levels. We undertook a randomized clinical trial in 140 patients undergoing thrice-weekly dialysis and assigned patients randomly to a standard or high dose of dialysis; Hb level was measured every month for 12 months. In the standard-dose group, the mean (±SD) urea reduction ratio was 65.1% ± 7.3%, the single-pool Kt/V was 1.26 ± 0.11, and the equilibrated Kt/V was 1.05 ± 0.09; in the high-dose group, the values were 73.5% ± 8.7%, 1.68 ± 0.15, and 1.47 ± 0.11, respectively. The standard deviation (SD) and residual SD (liner regression of Hb) values of Hb were significantly higher in the standard-dose group and low-flux group. The percentage achievement of target Hb in the high-dose dialysis group and high-flux dialyzer group was significantly higher than the standard-dose group and low-flux group, respectively. Patients undergoing hemodialysis thrice weekly appear to have benefit from a higher dialysis dose than that recommended by current KDQQI (Kidney Disease Qutcome Quality Initiative) guidelines or from the use of a high-flux membrane, which is in favor of maintaining stable Hb levels.
Collapse
Affiliation(s)
- Liyu He
- Key Laboratory of Kidney Disease and Blood Purification in Hunan, Nephrology Department, 2nd Xiangya Hospital, Central South University, Changsha, Hunan, China
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Rosati A, Tetta C, Merello JI, Palomares I, Perez-Garcia R, Maduell F, Canaud B, Aljama Garcia P. Cumulative iron dose and resistance to erythropoietin. J Nephrol 2014; 28:603-13. [PMID: 25091785 DOI: 10.1007/s40620-014-0127-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 07/25/2014] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Optimizing anemia treatment in hemodialysis (HD) patients remains a priority worldwide as it has significant health and financial implications. Our aim was to evaluate in a large cohort of chronic HD patients in Fresenius Medical Care centers in Spain the value of cumulative iron (Fe) dose monitoring for the management of iron therapy in erythropoiesis-stimulating agent (ESA)-treated patients, and the relationship between cumulative iron dose and risk of hospitalization. METHODS Demographic, clinical and laboratory parameters from EuCliD(®) (European Clinical Dialysis Database) on 3,591 patients were recorded including ESA dose (UI/kg/week), erythropoietin resistance index (ERI) [U.I weekly/kg/gr hemoglobin (Hb)] and hospitalizations. Moreover the cumulative Fe dose (mg/kg of bodyweight) administered over the last 2 years was calculated. Univariate and multivariate analyses were performed to identify the main predictors of ESA resistance and risk of hospitalization. Patients belonging to the 4th quartile of ERI were defined as hypo-responders. RESULTS The 2-year iron cumulative dose was significantly higher in the 4th quartile of ERI. In hypo-responders, 2-year cumulative iron dose was the only iron marker associated with ESA resistance. At case-mix adjusted multivariate analysis, 2-year iron cumulative dose was an independent predictor of hospitalization risk. DISCUSSION In ESA-treated patients cumulative Fe dose could be a useful tool to monitor the appropriateness of Fe therapy and to prevent iron overload. To establish whether the associations between cumulative iron dose, ERI and hospitalization risk are causal or attributable to selection bias by indication, clinical trials are necessary.
Collapse
Affiliation(s)
- A Rosati
- Department of Nephrology, Dialysis and Transplantation, Campo di Marte Regional Hospital, USL 2, Lucca, Italy.
| | - C Tetta
- EMEALA Medical Board, Fresenius Medical Care Deutschland GmbH, Else Kroener Strasse 1, Bad Homburg, Germany.
| | - J I Merello
- Medical Department, Fresenius Medical Care, Madrid, Spain
| | - I Palomares
- Medical Department, Fresenius Medical Care, Madrid, Spain
| | - R Perez-Garcia
- Department of Nephrology, Infanta Leonor University Hospital, Madrid, Spain
| | - F Maduell
- Department of Nephrology, Hospital Clínic, Barcelona, Spain
| | - B Canaud
- EMEALA Medical Board, Fresenius Medical Care Deutschland GmbH, Else Kroener Strasse 1, Bad Homburg, Germany
| | - P Aljama Garcia
- Department of Nephrology, Reina Sofía University Hospital, Córdoba, Spain
| |
Collapse
|
18
|
van der Weerd NC, Den Hoedt CH, Blankestijn PJ, Bots ML, van den Dorpel MA, Lévesque R, Mazairac AHA, Nubé MJ, Penne EL, ter Wee PM, Grooteman MPC. Resistance to erythropoiesis stimulating agents in patients treated with online hemodiafiltration and ultrapure low-flux hemodialysis: results from a randomized controlled trial (CONTRAST). PLoS One 2014; 9:e94434. [PMID: 24743493 PMCID: PMC3990567 DOI: 10.1371/journal.pone.0094434] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 03/14/2014] [Indexed: 12/17/2022] Open
Abstract
Resistance to erythropoiesis stimulating agents (ESA) is common in patients undergoing chronic hemodialysis (HD) treatment. ESA responsiveness might be improved by enhanced clearance of uremic toxins of middle molecular weight, as can be obtained by hemodiafiltration (HDF). In this analysis of the randomized controlled CONvective TRAnsport STudy (CONTRAST; NCT00205556), the effect of online HDF on ESA resistance and iron parameters was studied. This was a pre-specified secondary endpoint of the main trial. A 12 months' analysis of 714 patients randomized to either treatment with online post-dilution HDF or continuation of low-flux HD was performed. Both groups were treated with ultrapure dialysis fluids. ESA resistance, measured every three months, was expressed as the ESA index (weight adjusted weekly ESA dose in daily defined doses [DDD]/hematocrit). The mean ESA index during 12 months was not different between patients treated with HDF or HD (mean difference HDF versus HD over time 0.029 DDD/kg/Hct/week [−0.024 to 0.081]; P = 0.29). Mean transferrin saturation ratio and ferritin levels during the study tended to be lower in patients treated with HDF (−2.52% [−4.72 to −0.31]; P = 0.02 and −49 ng/mL [−103 to 4]; P = 0.06 respectively), although there was a trend for those patients to receive slightly more iron supplementation (7.1 mg/week [−0.4 to 14.5]; P = 0.06). In conclusion, compared to low-flux HD with ultrapure dialysis fluid, treatment with online HDF did not result in a decrease in ESA resistance. Trial Registration ClinicalTrials.gov NCT00205556
Collapse
Affiliation(s)
- Neelke C. van der Weerd
- Department of Nephrology, Academic Medical Center, Amsterdam, The Netherlands
- Department of Nephrology, VU Medical Center, Amsterdam, The Netherlands
- * E-mail:
| | - Claire H. Den Hoedt
- Department of Nephrology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Internal Medicine, Maasstad Hospital, Rotterdam, The Netherlands
| | - Peter J. Blankestijn
- Department of Nephrology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michiel L. Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Renée Lévesque
- Department of Nephrology, Centre Hospitalier de l'Université de Montréal, St-Luc Hospital, Québec, Canada
| | - Albert H. A. Mazairac
- Department of Nephrology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Menso J. Nubé
- Department of Nephrology, VU Medical Center, Amsterdam, The Netherlands
- Institute for Cardiovascular Research VU Medical Center (ICaR-VU), VU Medical Center, Amsterdam, The Netherlands
| | - E. Lars Penne
- Department of Nephrology, VU Medical Center, Amsterdam, The Netherlands
- Department of Internal Medicine, Medical Center Alkmaar, Alkmaar, The Netherlands
| | - Pieter M. ter Wee
- Department of Nephrology, VU Medical Center, Amsterdam, The Netherlands
- Institute for Cardiovascular Research VU Medical Center (ICaR-VU), VU Medical Center, Amsterdam, The Netherlands
| | - Muriel P. C. Grooteman
- Department of Nephrology, VU Medical Center, Amsterdam, The Netherlands
- Institute for Cardiovascular Research VU Medical Center (ICaR-VU), VU Medical Center, Amsterdam, The Netherlands
| | | |
Collapse
|
19
|
Okazaki M, Komatsu M, Kawaguchi H, Tsuchiya K, Nitta K. Erythropoietin Resistance Index and the All-Cause Mortality of Chronic Hemodialysis Patients. Blood Purif 2014; 37:106-12. [DOI: 10.1159/000358215] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 12/22/2013] [Indexed: 11/19/2022]
|
20
|
Kalim S, Tamez H, Wenger J, Ankers E, Trottier CA, Deferio JJ, Berg AH, Karumanchi SA, Thadhani RI. Carbamylation of serum albumin and erythropoietin resistance in end stage kidney disease. Clin J Am Soc Nephrol 2013; 8:1927-34. [PMID: 23970130 DOI: 10.2215/cjn.04310413] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The mechanisms underlying erythropoietin resistance are not fully understood. Carbamylation is a post-translational protein modification that can alter the function of proteins, such as erythropoietin. The hypothesis of this study is that carbamylation burden is independently associated with erythropoietin resistance. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a nonconcurrent prospective cohort study of incident hemodialysis patients in the United States, carbamylated albumin, a surrogate of overall carbamylation burden, in 158 individuals at day 90 of dialysis initiation and erythropoietin resistance index (defined as average weekly erythropoietin dose [U] per kg body weight per hemoglobin [g/dl]) over the subsequent 90 days were measured. Linear regression was used to describe the relationship between carbamylated albumin and erythropoietin resistance index. Logistic regression characterized the relationship between erythropoietin resistance index, 1-year mortality, and carbamylation. RESULTS The median percent carbamylated albumin was 0.77% (interquartile range=0.58%-0.93%). Median erythropoietin resistance index was 18.7 units/kg per gram per deciliter (interquartile range=8.1-35.6 units/kg per gram per deciliter). Multivariable adjusted analysis showed that the highest quartile of carbamylated albumin was associated with a 72% higher erythropoietin resistance index compared with the lowest carbamylation quartile (P=0.01). Increasing erythropoietin resistance index was associated with a higher risk of death (odds ratio per unit increase in log-erythropoietin resistance index, 1.69; 95% confidence interval, 1.06 to 2.70). However, the association between erythropoietin resistance index and mortality was no longer statistically significant when carbamylation was included in the analysis (odds ratio, 1.44; 95% confidence interval, 0.87 to 2.37), with carbamylation showing the dominant association with death (odds ratio for high versus low carbamylation quartile, 4.53; 95% confidence interval, 1.20 to 17.10). CONCLUSION Carbamylation was associated with higher erythropoietin resistance index in incident dialysis patients and a better predictor of mortality than erythropoietin resistance index.
Collapse
Affiliation(s)
- Sahir Kalim
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts;, †Department of Pathology, Division of Clinical Chemistry and, ‡Department of Medicine, Division of Nephrology and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Locatelli F, Altieri P, Andrulli S, Sau G, Bolasco P, Pedrini LA, Basile C, David S, Feriani M, Nebiolo PE, Ferrara R, Casu D, Logias F, Tarchini R, Cadinu F, Passaghe M, Fundoni G, Villa G, Di Iorio BR, Zoccali C. Predictors of haemoglobin levels and resistance to erythropoiesis-stimulating agents in patients treated with low-flux haemodialysis, haemofiltration and haemodiafiltration: results of a multicentre randomized and controlled trial. Nephrol Dial Transplant 2012; 27:3594-600. [PMID: 22622452 PMCID: PMC3433772 DOI: 10.1093/ndt/gfs117] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background Predictors of haemoglobin (Hb) levels and resistance to erythropoiesis-stimulating agents (ESAs) in dialysis patients have not yet been clearly defined. Some mainly uncontrolled studies suggest that online haemodiafiltration (HDF) may have a beneficial effect on Hb, whereas no data are available concerning online haemofiltration (HF). The objectives of this study were to evaluate the effects of convective treatments (CTs) on Hb levels and ESA resistance in comparison with low-flux haemodialysis (HD) and to evaluate the predictors of these outcomes. Methods Primary multivariate analysis was made of a pre-specified secondary outcome of a multicentre, open-label, randomized controlled study in which 146 chronic HD patients from 27 Italian centres were randomly assigned to HD (70 patients) or CTs: online pre-dilution HF (36 patients) or online pre-dilution HDF (40 patients). Results CTs did not affect Hb levels (P = 0.596) or ESA resistance (P = 0.984). Hb correlated with polycystic kidney disease (P = 0.001), C-reactive protein (P = 0.025), ferritin (P = 0.018), ESA dose (P < 0.001) and total cholesterol (P = 0.021). The participating centres were the main source of Hb variability (partial eta2 0.313, P < 0.001). ESA resistance directly correlated with serum ferritin (P = 0.030) and beta2 microglobulin (P = 0.065); participating centres were again a major source of variance (partial eta2 0.367, P < 0.001). Transferrin saturation did not predict either outcome variables (P = 0.277 and P = 0.170). Conclusions In comparison with low-flux HD, CTs did not significantly improve Hb levels or ESA resistance. The main sources of variability were participating centres, ESA dose and the underlying disease.
Collapse
Affiliation(s)
- Francesco Locatelli
- Department of Nephrology and Dialysis, Azienda Ospedaliera della Provincia di Lecco, Ospedale Alessandro Manzoni, Lecco, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Mallick S, Rafiroiu A, Kanthety R, Iqbal S, Malik R, Rahman M. Factors Predicting Erythropoietin Resistance among Maintenance Hemodialysis Patients. Blood Purif 2012; 33:238-44. [DOI: 10.1159/000335256] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 11/18/2011] [Indexed: 11/19/2022]
|
23
|
Derebail VK, Nachman PH, Key NS, Ansede H, Falk RJ, Rosamond WD, Kshirsagar AV. Variant hemoglobin phenotypes may account for differential erythropoiesis-stimulating agent dosing in African-American hemodialysis patients. Kidney Int 2011; 80:992-999. [PMID: 21849972 DOI: 10.1038/ki.2011.247] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
African-American patients with end-stage renal disease have historically lower hemoglobin concentrations and higher requirements of erythropoiesis-stimulating agent (ESA). While disparities in health-care access may partially explain these findings, the role of variant hemoglobin, such as sickle trait, has not been investigated. To clarify this, we evaluated 154 African-American patients receiving in-center hemodialysis with available hemoglobin phenotyping. The primary exposure was any abnormal hemoglobin variant and the primary outcome of higher-dose ESA was defined as a dose of 6500 or more units per treatment. Logistic regression assessed the association between variant hemoglobin and higher-dose ESA. Covariates included age, gender, diabetes, iron parameters, intravenous iron dose, parathyroid hormone, albumin, phosphorus, body mass index, vascular access type, hospitalization/missed treatments, smoking status, alcohol abuse, and gastrointestinal bleeding. Of 33 patients with variant hemoglobin, 24 had HbAS and 9 had HbAC. Univariate odds of higher-dose ESA among those with hemoglobin variants were twice that of those with the normal HbAA phenotype (odds ratio 2.05). In multivariate models, the likelihood of higher-dose ESA had an odds ratio of 3.31 and the nature of this relationship did not change in Poisson regression or sensitivity analyses. Hence, our findings may explain, in part, the difference in ESA dosing between Caucasians and African-Americans with end-stage renal disease but await further study.
Collapse
Affiliation(s)
- Vimal K Derebail
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
| | - Patrick H Nachman
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nigel S Key
- Division of Hematology and Oncology, and Program in Hemostasis and Thrombosis, Department of Medicine, Carolina Cardiovascular Biology Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Ronald J Falk
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Abhijit V Kshirsagar
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| |
Collapse
|
24
|
Bowry SK, Gatti E. Impact of Hemodialysis Therapy on Anemia of Chronic Kidney Disease: The Potential Mechanisms. Blood Purif 2011; 32:210-9. [DOI: 10.1159/000329573] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
25
|
Perrinet M, Décaudin B, Champs BBD, Heran I, Urbina MA, Lemaitre V, Azar R, Odou P. Chronic dialysis-associated anaemia in end-stage renal disease: analysis of management in two French centres. J Clin Pharm Ther 2010; 35:395-400. [PMID: 20831542 DOI: 10.1111/j.1365-2710.2009.01106.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Treatment of anaemia in renal-insufficient patients relies on the use of an erythropoiesis-stimulating agent (ESA). This study aimed to compare the impact of two different strategies of ESA prescribing on variation in haemoglobin (Hb) concentration in end-stage renal disease (ESRD) patients. METHODS Patients with ESRD, on haemodialysis, and who had received ESA for >3 months were recruited. Different parameters were analysed: demographics, Hb level the last day of the year before dialysis, the most recent weekly ESA dose, risk factors for resistance and cost. Each institution continued its local practice for achieving the desired Hb level: increasing the ESA dose to overcome resistance in one centre and defining an upper ESA-dose limit in the other. RESULTS A total of 185 patients were recruited. No significant differences in the biological parameters were found between the two populations. In both centres, Hb levels were comparable and mean levels exceeded 11 g/dL, despite the higher ESA doses given in one centre to achieve this target. This finding also held true for the subgroups with greater than or equal to two resistance factors. These two strategies led to large between-centre differences in treatment costs. CONCLUSION The ESA-use strategy difference probably indicates that erythropoietin-resistance was not overcome with increased dosing. The Hb concentrations remained stable even when ESA doses were increased. On current evidence, the cheaper ESA-dose limitation strategy is preferable but randomized controlled studies, including comparisons of alternative ESA formulations are necessary.
Collapse
Affiliation(s)
- M Perrinet
- Pharmacy, Dunkerque General Hospital, Dunkerque, France
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Gaweda AE, Goldsmith LJ, Brier ME, Aronoff GR. Iron, inflammation, dialysis adequacy, nutritional status, and hyperparathyroidism modify erythropoietic response. Clin J Am Soc Nephrol 2010; 5:576-81. [PMID: 20110344 DOI: 10.2215/cjn.04710709] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The erythropoietic response in hemodialysis patients depends on several physiologic factors. Most epidemiologic studies include the effect of these factors by representing them as confounders. This study tested the hypothesis that iron stores, inflammation, dialysis adequacy, nutritional status, and hyperparathyroidism act as nonlinear effect modifiers of the erythropoietic response and quantified the magnitude of those effects over clinically relevant ranges. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The following retrospective data from 209 hemodialysis patients receiving Epoetin alfa (Epo) were collected: monthly: predialysis hemoglobin (Hgb), transferrin saturation, serum albumin, dialysis adequacy (Kt/V); quarterly: predialysis serum ferritin and intact parathyroid hormone over a period of 13 to 69 months. The study analyzed the dynamic relationship between hemoglobin and Epo, considering nonlinear effect modification by ferritin, transferrin saturation, Kt/V, albumin, and parathyroid hormone individually. RESULTS Maximum Hgb response to Epo was achieved for serum ferritin between 350 and 500 ng/ml, transferrin saturation greater than 30%, Kt/V greater than 1.4, and albumin greater than 3.8 g/dl. Hgb sensitivity to Epo decreases by about 30% as parathyroid hormone increases from 0 through 1000 pg/ml. CONCLUSIONS Serum ferritin, transferrin saturation, Kt/V, serum albumin, and intact parathyroid hormone are markers of nonlinear effect modification of the erythropoietic response in hemodialysis patients.
Collapse
Affiliation(s)
- Adam E Gaweda
- University of Louisville, Department of Medicine, Division of Nephrology, 615 South Preston Street, Louisville, KY 40202, USA.
| | | | | | | |
Collapse
|
27
|
Rottembourg J, Kpade F, Dansaert A, Chenuc G. Timing of the administration of intravenous darbepoetin alfa during the dialysis session: Does it impact efficacy? ACTA ACUST UNITED AC 2009. [DOI: 10.1002/dat.20397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
28
|
López-Gómez JM, Portolés JM, Aljama P. Factors that condition the response to erythropoietin in patients on hemodialysis and their relation to mortality. Kidney Int 2009:S75-81. [PMID: 19034333 DOI: 10.1038/ki.2008.523] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The response to erythropoietin-stimulating agents (ESA) can vary among different patients and according to the different circumstances over time within a given individual. The aim of this study was to analyze the factors that can modify the response to epoetin in patients on hemodialysis (HD) and its influence on early mortality. Prospective and observational study including 1710 patients from 119 HD units in Spain with a follow-up of 12 months. To evaluate the dose-response effect of EPO therapy, we used the erythropoietin resistance index (ERI), calculated as the weekly weight-adjusted dose of EPO divided by the hemoglobin level. Patients were stratified in three groups according to ERI: group A, ERI <5; group B, ERI=5-15; group C, ERI>15 U/kg/week/g per 100 ml. Mean ERI for the entire group was 10.2+/-7.3 U/kg/week/g per 100 ml. ERI was directly related with incident comorbidity (Charlson Index), age, female gender and low body mass index with no relationship with etiology of chronic kidney disease. Patients with antecedents of heart failure, acute infection or malignant neoplasm had significantly higher ERI than those without. Transferrin saturation index, but not serum ferritin, was inversely related with ERI. Serum levels of albumin and cholesterol were related with lower ERI, but no relation was found with normalized protein catabolic rate. Patients with a permanent catheter for HD had significant higher values of ERI than those with native fistula (P=0.012). One year survival in all three groups of patients according to ERI was 0.916 in group A, 0.877 in group B and 0.788 in group C (log-rank=20.7, P<0.001). The resistance to ESA is directly related with incident comorbidity in patients on hemodialysis and it can be interpreted as a useful marker of early mortality.
Collapse
Affiliation(s)
- Juan M López-Gómez
- Service of Nephrology, Hospital Universitario Gregorio Marañón, Madrid, Spain.
| | | | | |
Collapse
|
29
|
Wystrychowski G, Kitzler TM, Thijssen S, Usvyat L, Kotanko P, Levin NW. Impact of switch of vascular access type on key clinical and laboratory parameters in chronic haemodialysis patients. Nephrol Dial Transplant 2009; 24:2194-200. [PMID: 19228757 DOI: 10.1093/ndt/gfp052] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Observational studies demonstrate poor clinical outcomes in chronic haemodialysis patients with venous catheters as vascular access. This longitudinal study examines the impact of vascular access change on key clinical and laboratory parameters. METHODS We studied 2616 haemodialysis patients who had no or one vascular access change between January 2002 and June 2003. Two hundred and seventy-one patients switched from a catheter to an arteriovenous (AV) access (AV fistula or graft) and 69 patients from an AV access to a catheter. Accesses remained unchanged in 430 patients with catheters, and in 1846 patients with an AV access, who served as controls. Levels of serum albumin, white blood cell count (WBC), enPCR, eKdrt/V, blood haemoglobin and erythropoietin dosage were obtained monthly. Data were averaged over 6 months preceding (pre) and 6 months following the access change (post). Differences between post- and pre-access change were compared to changes in respective parameters between the last and first 6 months of the study period in controls. RESULTS The change from a catheter to an AV access was associated with a rise of serum albumin (+0.12 g/dL; P < 0.001), enPCR (+0.05 g/kg body weight/day; P = 0.001) and haemoglobin (+0.41 g/dL; P < 0.001) and a decrease in WBC (-370/microL; P = 0.048). Conversely, switching from an AV access to a catheter was followed by a significant fall in albumin (-0.11 g/dL; P = 0.035), enPCR (-0.07 g/ kg body weight/day; P = 0.001) and eKdrt/V (-0.09; P < 0.001) and a rise in erythropoietin dosage (+89 IU/kg body weight/week; P = 0.002), as compared to controls. CONCLUSION Change from a catheter to an AV access seems to alleviate malnutrition, inflammation and anaemia. Efforts to replace catheters with fistulae or grafts should be intensified.
Collapse
|
30
|
Abstract
Approximately 5-10% of patients with chronic kidney disease demonstrate hyporesponsiveness to erythropoiesis-stimulating agents (ESA), defined as a continued need for greater than 300 IU/kg per week erythropoietin or 1.5 mug/kg per week darbepoetin administered by the subcutaneous route. Such hyporesponsiveness contributes significantly to morbidity, mortality and health-care economic burden in chronic kidney disease and represents an important diagnostic and management challenge. The commonest causes of ESA resistance are non-compliance, absolute or functional iron deficiency and inflammation. It is widely accepted that maintaining adequate iron stores, ideally by administering iron parenterally, is the most important strategy for reducing the requirements for, and enhancing the efficacy of ESA. There have been recent epidemiologic studies linking parenteral iron therapy to an increased risk of infection and atherosclerosis, although other investigations have refuted this. Inflammatory ESA hyporesponsiveness has been reported to be improved by a number of interventions, including the use of biocompatible membranes, ultrapure dialysate, transplant nephrectomy, ascorbic acid therapy, vitamin E supplementation, statins and oxpentifylline administration. Other variably well-established causes of ESA hyporesponsiveness include inadequate dialysis, hyperparathyroidism, nutrient deficiencies (vitamin B12, folate, vitamin C, carnitine), angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, aluminium overload, antibody-mediated pure red cell aplasia, primary bone marrow disorders, myelosuppressive agents, haemoglobinopathies, haemolysis and hypersplenism. This paper reviews the causes of ESA hyporesponsiveness and the clinical evidence for proposed therapeutic interventions. A practical algorithm for approaching the investigation and management of patients with ESA hyporesponsiveness is also provided.
Collapse
Affiliation(s)
- David W Johnson
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia.
| | | | | |
Collapse
|
31
|
Pauly RP, Chan CT. CARDIOVASCULAR AND SURVIVAL PARADOXES IN DIALYSIS PATIENTS: Reversing the Risk Factor Paradox: Is Daily Nocturnal Hemodialysis the Solution? Semin Dial 2007; 20:539-43. [DOI: 10.1111/j.1525-139x.2007.00344.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
32
|
Wei M, Bargman JM, Oreopoulos DG. Factors related to erythropoietin hypo-responsiveness in patients on chronic peritoneal dialysis. Int Urol Nephrol 2007; 39:935-40. [PMID: 17534732 DOI: 10.1007/s11255-007-9226-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Accepted: 04/05/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND The present study was aimed at investigating the factors related to hypo-responsiveness to erythropoietin in patients on chronic peritoneal dialysis (PD). METHODS We studied 44 patients with end-stage renal disease who had been on PD for more than 6 months and on erythropoietin (EPO) >/=6,000 U/week for more than 3 months. We expressed EPO resistance index (ERI) as weekly EPO dose per hematocrit (Hct) per body weight. The dose of EPO was titrated to maintain a target Hct level between 33% and 36%. Patients were divided into two groups according to weekly EPO dose. We compared the various factors in those two groups and, by using correlation and linear regression analysis, investigated factors that might predict EPO resistance. RESULTS There were 13 patients in the EPO <150 U/kg per week group and 31 patients in the EPO >/=150 U/kg per week group. Among those 31 patients, there were five patients on EPO >/=300 U/kg per week. Compared to the EPO <150 U/kg per week group, the EPO >/=150 U/kg per week group had a lower normalized protein catabolic rate (nPCR), lower level of serum albumin and higher C-reactive protein (CRP). Correlation analysis showed that the ERI had a statistically significant correlation with CRP (r = 0.303, P < 0.05), serum albumin (r = -0.26, P < 0.05), parathyroid hormone (PTH) (r = -0.307, P < 0.05) and nPCR (r = -0.259, P < 0.05). These results show that CRP, serum albumin, PTH and nPCR are factors related to hypo-responsiveness. Multiple stepwise linear regression analysis showed that CRP was the most important independent predictor of EPO hypo-responsiveness. CONCLUSION CRP, serum albumin, nPCR and PTH are factors related to hypo-responsiveness. Inflammation contributes significantly to EPO hypo-responsiveness.
Collapse
Affiliation(s)
- Mingxin Wei
- Home Peritoneal Dialysis Unit, University Health Network and University of Toronto, Toronto, ON, Canada
| | | | | |
Collapse
|
33
|
Hedges SJ, Dehoney SB, Hooper JS, Amanzadeh J, Busti AJ. Evidence-based treatment recommendations for uremic bleeding. ACTA ACUST UNITED AC 2007; 3:138-53. [PMID: 17322926 DOI: 10.1038/ncpneph0421] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2006] [Accepted: 12/08/2006] [Indexed: 12/16/2022]
Abstract
Uremic bleeding syndrome is a recognized consequence of renal failure and can result in clinically significant sequelae. Although the pathophysiology of the condition has yet to be fully elucidated, it is believed to be multifactorial. This article is a review of both the normal hemostatic and homeostatic mechanisms that operate within the body to prevent unnecessary bleeding, as well as an in-depth discussion of the dysfunctional components that contribute to the complications associated with uremic bleeding syndrome. As a result of the multifactorial nature of this syndrome, prevention and treatment options can include one or a combination of the following: dialysis, erythropoietin, cryoprecipitate, desmopressin, and conjugated estrogens. Here, these treatment options are compared with regard to their mechanism of action, and onset and duration of efficacy. An extensive review of the clinical trials that have evaluated each treatment is also presented. Lastly, we have created an evidence-based treatment algorithm to help guide clinicians through most clinical scenarios, and answered common questions related to the management of uremic bleeding.
Collapse
|
34
|
Locatelli F, Del Vecchio L, Pozzoni P, Andrulli S. Dialysis adequacy and response to erythropoiesis-stimulating agents: what is the evidence base? Semin Nephrol 2007; 26:269-74. [PMID: 16949464 DOI: 10.1016/j.semnephrol.2006.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Despite an increase in the use and average dose of erythropoiesis-stimulating agents (ESA) over the past 15 years, a substantial percentage of patients still do not achieve hemoglobin targets recommended by international guidelines. A clear relationship among hemoglobin or hematocrit levels, ESA dose, and increase in dialysis dose has been pointed out by a number of prospective or retrospective studies. This is particularly true in patients receiving inadequate dialysis. Increasing attention also has been paid to the relationship between dialysis, increased inflammatory stimulus, and ESA response because dialysate contamination and low-compatible treatments may increase cytokine production and consequently inhibit erythropoiesis. The biocompatibility of dialysis membranes and flux are other important factors. However, in highly selected, adequately dialyzed patients without iron or vitamin depletion, the effect of these treatment modalities on anemia seems to be smaller than expected. The role of on-line treatments still is controversial given that it is still difficult to discriminate between the effect of on-line hemodiafiltration per se from that of an increased dialysis dose. Very preliminary results obtained with short or long nocturnal daily hemodialysis on anemia correction are encouraging.
Collapse
Affiliation(s)
- Francesco Locatelli
- The Department of Nephrology and Dialysis, Ospedale A. Manzoni, Lecco, Italy.
| | | | | | | |
Collapse
|
35
|
Priyadarshi A, Shapiro JI. HEMATOLOGY: ISSUES IN THE DIALYSIS PATIENT: Erythropoietin Resistance in the Treatment of the Anemia of Chronic Renal Failure. Semin Dial 2006; 19:273-8. [PMID: 16893403 DOI: 10.1111/j.1525-139x.2006.00172.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Resistance to erythropoietin therapy is a common complication of the modern management of anemia in chronic kidney disease. Iron deficiency, deficiency of other nutrients, toxins, infections, and inadequate dialysis account for the vast majority of episodes of such resistance.
Collapse
Affiliation(s)
- Anumeet Priyadarshi
- Department of Medicine, Medical University of Ohio, Toledo, Ohio 43614-5089, USA
| | | |
Collapse
|
36
|
References. Am J Kidney Dis 2006. [DOI: 10.1053/j.ajkd.2006.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
37
|
Maduell F, Navarro V. Bases of cardiovascular and hematological effects. Hemodial Int 2006; 10 Suppl 1:S39-42. [PMID: 16441867 DOI: 10.1111/j.1542-4758.2006.01189.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
38
|
Yuen D, Richardson RMA, Fenton SSA, McGrath-Chong ME, Chan CT. Quotidian nocturnal hemodialysis improves cytokine profile and enhances erythropoietin responsiveness. ASAIO J 2005; 51:236-41. [PMID: 15968953 DOI: 10.1097/01.mat.0000160578.43422.60] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Inflammation is implicated in the pathogenesis of erythropoietin (EPO) resistance in patients with end-stage renal disease. Interleukin (IL)-6 and tumor necrosis factor (TNF)-alpha are suggested to suppress erythropoiesis in uremia. Insulin like growth factor (IGF)-1 has been proposed to stimulate erythropoiesis. Nocturnal hemodialysis (NHD) has been demonstrated to improve anemia management with enhanced EPO responsiveness without altering survival of red blood cells. We tested the hypothesis that augmentation of uremia clearance by NHD results in a reduction of proinflammatory cytokine levels, thereby enhancing EPO responsiveness. Using a cross-sectional study design, 14 prevalent patients on NHD and 14 patients on conventional hemodialysis (CHD) matched for age and comorbidities and controlled for hemoglobin concentrations and iron status were studied. Outcome variables included EPO requirement and plasma levels of EPO, parathyroid hormone, C reactive protein, IL-6, TNF-alpha, and IGF-1. The primary outcome was to determine the between group differences in (1) cytokine profile and (2) EPO requirement. The secondary outcome was to examine the potential correlation between cytokine levels and EPO requirement. There were no significant differences in patient characteristics, comorbidities, hemoglobin, iron indices, and parathyroid hormone levels between the two cohorts. EPO requirement was significantly lower in the NHD cohort [90.5 +/- 22.1 U/kg/ week (NHD) vs. 167.2 +/- 25.4 U/kg/week (CHD), p = 0.04]. Plasma IL-6 levels were lower in the NHD cohort [3.9 +/- 0.7 pg/ml (NHD) vs. 6.5 +/- 0.8 pg/ml (CHD), p = 0.04]. C reactive protein tended to decrease [4.59 +/- 1.34 (NHD) vs. 8.43 +/- 1.83 mg/L (CHD), p = 0.14]. TNF-alpha, and IGF-1 levels did not differ between the two groups. Direct associations were found between EPO requirement and C reactive protein levels (R = 0.62, p = 0.001), and IL-6 levels (R = 0.57, p = 0.002). Augmentation of uremic clearance by NHD improves EPO responsiveness in end-stage renal disease. A possible mechanism for this improvement is through better control of inflammation, as manifested by lowering of plasma IL-6 levels. Further studies are required to clarify the mechanisms by which NHD decreases inflammation.
Collapse
Affiliation(s)
- Darren Yuen
- Department of Medicine, Division of Nephrology, Toronto General Hospital-University Health Network, University of Toronto, Canada
| | | | | | | | | |
Collapse
|
39
|
Argumentaire. Nephrol Ther 2005. [DOI: 10.1016/s1769-7255(05)80005-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
40
|
McIntyre CW, Hulme LJ, Taal M, Fluck RJ. Locking of tunneled hemodialysis catheters with gentamicin and heparin. Kidney Int 2004; 66:801-5. [PMID: 15253736 DOI: 10.1111/j.1523-1755.2004.00806.x] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Catheter-related infection (CRI) is a major cause of morbidity and mortality in patients receiving hemodialysis. Antibiotic locking of these catheters has been shown to increase both the success of systemic antibiotic treatment in line sepsis, and to reduce the incidence of sepsis. We have studied the use of gentamicin locking of catheters (in combination with standard heparin rather than previously reported citrate) to reduce CRI rates. Furthermore, we have investigated the effects of this strategy on epoetin requirements and vascular access function. METHODS Fifty patients were studied. Patients were randomized to catheter-restricted filling with either standard heparin (5000 IU/mL) alone, or gentamicin and heparin (5 mg/mL). Epoetin requirements and hemoglobin response were monitored over the study period. RESULTS The gentamicin-locked group suffered only one infective episode (0.3/1000 catheter days) compared to 10 episodes in six patients in the heparin alone group (4/1000 catheter days, P= 0.02). The isolated organisms were equally split between Staphylococcal species and coliforms. There were no statistically significant differences in delivered dialysis dose (Kt/V) or QA between the two groups. Use of antibiotic locking was associated with both a higher mean hemoglobin (10.1 +/-0.14 g/dL vs. 9.2 +/- 0.17 g/dL in the heparin group, P= 0.003) and a lower mean epoetin dose (9000 +/- 734 IU/week vs. 10790 +/-615 IU/week in the heparin group, P= 0.04). CONCLUSION The practice of locking newly inserted tunneled central venous catheters with gentamicin and heparin is an effective strategy to reduce line sepsis rates, and is associated with beneficial effects on epoetin requirements.
Collapse
|
41
|
Di Iorio BR, Minutolo R, De Nicola L, Bellizzi V, Catapano F, Iodice C, Rubino R, Conte G. Supplemented very low protein diet ameliorates responsiveness to erythropoietin in chronic renal failure. Kidney Int 2004; 64:1822-8. [PMID: 14531817 DOI: 10.1046/j.1523-1755.2003.00282.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the relationship between uremic state and erythropoiesis in patients with predialytic chronic renal failure (CRF). METHODS We monitored for 2 years the erythropoietin (EPO) requirement in patients with advanced CRF (creatinine clearance < or =25 mL/min), randomized to either low protein diet (LPD) group (0.6 g/kg body weight/day, N = 10) or very low protein diet (VLPD) group (0.3 g/kg body weight/day, N = 10) supplemented with a mixture of ketoanalogs and essential amino acids, both kept at target hemoglobin levels. RESULTS The achieved protein intake after 6 months was 0.79 +/- 0.02 g/kg body weight/day and 0.50 +/- 0.02 g/kg body weight/day in LPD and VLPD, respectively; such a difference was maintained up to the end of follow up. The final hemoglobin values did not differ from the basal values in either group (11.5 +/- 0.2 g/dL and 11.5 +/- 0.3 g/dL). EPO dose, that was similar at baseline (62.4 +/- 9.6 UI/kg body weight/week and 61.8 +/- 8.8 UI/kg body weight/week subcutaneously), remained unchanged in LPD but progressively decreased in VLPD down to the final value of 41.2 +/- 7.0 UI/kg body weight/week (P < 0.0001 vs. basal and LPD). VLPD was associated with a decrease of urinary excretion and serum levels of urea nitrogen and phosphate; however, EPO requirement was not correlated with the changes of these parameters. On the contrary, the variation of EPO dose directly correlated with the modification of parathyroid hormone (PTH) levels, that diminished from 229 +/- 55 pg/mL to 118 +/- 16 pg/mL (P < 0.0001) in VLPD and did not change in LPD. CONCLUSION In patients with advanced CRF, an effective decrease of protein intake of 0.3 g/kg body weight/day induces a reduction of about 35% of the EPO dose required to maintain the target hemoglobin levels. This effect appears dependent on the correction of a moderate secondary hyperparathyroidism.
Collapse
Affiliation(s)
- Biagio R Di Iorio
- Department of Nephrology-School of Medicine, Second University of Naples, Naples, Italy
| | | | | | | | | | | | | | | |
Collapse
|
42
|
Berns JS, Elzein H, Lynn RI, Fishbane S, Meisels IS, Deoreo PB. Hemoglobin variability in epoetin-treated hemodialysis patients. Kidney Int 2003; 64:1514-21. [PMID: 12969173 DOI: 10.1046/j.1523-1755.2003.00229.x] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Understanding the clinical variability of hemoglobin measurements in epoetin-treated hemodialysis patients is important, particularly when this therapy is aimed at maintaining patient hemoglobin levels within a narrow range, such as the 11 to 12 g/dL range recommended in National Kidney Foundation Kidney Dialysis Outcomes Quality Initiative (NKF-K/DOQI) guidelines. This study examines hemoglobin variability under conditions of standard clinical practice in epoetin-treated hemodialysis patients. METHODS We studied 987 hemodialysis patients participating in an observational retrospective study that evaluated anemia management practices from October 1, 1996 to December 31, 1997 at 11 United States dialysis centers that were randomly selected from a pool of nearly all United States dialysis facilities. Each participating facility maintained its own anemia management protocols without specific anemia management recommendations or interventions made as part of this study. Hemoglobin variability was determined by calculating the 1-month and 2- to 6-month rolling average hemoglobin for each patient. The range of mean hemoglobin values that included the middle 50% (25th to 75th percentile), 80% (10th to 90th percentile), and 90% (5th to 95th percentile) of values were determined. The hemoglobin ranges that included 1 standard deviation (SD) (67%) of the study values and 2 SD (95%) of the study values for each time period were calculated. RESULTS The mean hemoglobin was between 10.9 and 11.2 g/dL throughout the study. The hemoglobin range encompassing 50%, 80%, and 90% of values from a single month was 1.7, 3.3, and 4.4 g/dL, respectively. A progressive narrowing in the range of hemoglobin values encompassed by each percentile grouping (i.e., hemoglobin variability) was observed as longer rolling intervals were averaged. The hemoglobin range within the 25th to 75th percentile was 1.7 g/dL using single-month hemoglobin values and 1.1 g/dL using a 6-month rolling average. The range of hemoglobin values that encompassed 90% of patients was 4.4 g/dL using single-month values, 3.7 g/dL using 3-month rolling averages, and 3.2 g/dL using 6-month rolling averages. Fewer than 50% of patients had hemoglobin values within the 1.0 g/dL NKF-K/DOQI recommended range, even when a 6-month rolling average was applied. When hemoglobin values were measured for 1 month, 1 SD was 1.4 g/dL; for the 3-month rolling average, 1 SD was 1.1 g/dL; and for the 4-, 5-, and 6-month rolling averages, 1 SD was 1.0 g/dL. Greater hemoglobin variability correlated with higher mean corpuscular hemoglobin (P = 0.003) and serum ferritin (P = 0.047), and inversely correlated with age (P = 0.006) and serum albumin (P = 0.0001). CONCLUSION Substantial variability occurs in hemoglobin values in epoetin-treated hemodialysis patients. The NKF-K/DOQI recommended hemoglobin range appears to be too narrow in clinical practice. Expanding the target range and use of rolling average hemoglobin intervals of 3 to 6 months as a clinical and quality assurance measure avoids clinical variability inherent with the use of isolated hemoglobin values or single-month hemoglobin averages.
Collapse
Affiliation(s)
- Jeffrey S Berns
- Renal, Electrolyte and Hypertension Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
| | | | | | | | | | | |
Collapse
|
43
|
Richardson D, Lindley EJ, Bartlett C, Will EJ. A randomized, controlled study of the consequences of hemodialysis membrane composition on erythropoietic response. Am J Kidney Dis 2003; 42:551-60. [PMID: 12955684 DOI: 10.1016/s0272-6386(03)00788-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Membrane biocompatibility has long been thought to be relevant to hemodialysis outcomes and, possibly, renal anemia. METHODS We performed a randomized, controlled, single-center study comparing the consequences on renal anemia of 2 dialyzers of equivalent performance, but different composition, during 7 months. Two hundred eleven patients of an unselected dialysis population of 235 patients gave informed consent to undergo random assignment to either group A (SF170E; modified cellulose triacetate/midflux membrane; Nipro, Osaka, Japan) or group B (HF80LS; polysulfone/high-flux membrane; Fresenius, Bad Homburg, Germany). Anemia management was identical in both treatment groups and followed strict clinical protocols managed by computer algorithms. Dialysis adequacy, hemoglobin (Hb) level, ferritin level, percentage of red blood cell hypochromicity, C-reactive protein (CRP) level, and intravenous iron and epoetin doses were monitored monthly. RESULTS One hundred seventy-seven patients completed the 7-month study. Equilibrated Kt/V increased in both groups. Hb outcome improved overall, but did not differ between the 2 study groups. Epoetin dose was not significantly different after 7 months compared with baseline in either group. Hb level, epoetin dose, iron status, CRP level, dialysis Kt/V, and residual renal function did not differ between the 2 groups. A slight but significant negative correlation was identified between dialysis Kt/V and Hb level in the population as a whole (Spearman's correlation, -0.16; P = 0.04). CONCLUSION No significant epoetin-sparing effect was identified through the use of the high-flux polysulfone HF80LS membrane over the modified cellulose triacetate SF170E membrane. Although not a primary outcome for this study, there was a suggestion of benefit of improved Hb level, without increased need for epoetin, through increasing delivered dialysis dose.
Collapse
Affiliation(s)
- Donald Richardson
- Department of Renal Medicine, St James's University Hospital, Leeds, UK.
| | | | | | | |
Collapse
|
44
|
Nakao K, Wada J, Ota K, Ichikawa H, Akagi S, Okamoto A, Hida K, Nagake Y, Makino H. Perturbation of autocrine/paracrine loops of burst-forming units of erythroid-derived cells in rHuEPO-hyporesponsive hemodialysis patients. Am J Kidney Dis 2003; 41:624-36. [PMID: 12612986 DOI: 10.1053/ajkd.2003.50124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Quantitative or qualitative abnormalities of erythroid progenitors in patients with chronic renal failure (CRF) could be the major factor for recombinant human erythropoietin (rHuEPO) hyporesponsiveness and severe anemia in hemodialysis (HD) patients receiving rHuEPO therapy. METHODS Purified 1 x 10(4) circulating CD34+ cells isolated from rHuEPO-hyporesponsive HD patients (EPO-H; n = 10), rHuEPO-responsive non-HD patients with CRF (EPO-R; n = 8), nonanemic HD patients without rHuEPO therapy (EPO-W/O; n = 10), and healthy volunteer controls (CON; n = 10) were subjected to a methylcellulose culture system supplemented with rHuEPO, recombinant human interleukin-3 (IL-3), recombinant human stem cell factor (SCF), and recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF) for 14 days. RESULTS The average number of burst-forming units of erythroids (BFU-Es) was significantly less in the EPO-H group compared with the CON and EPO-W/O groups. Furthermore, colony size also was significantly smaller in the EPO-H group. Total RNAs were extracted from approximately 100 colonies/patient and subjected to complementary DNA expression array studies of 268 growth factors, cytokines, chemokines, and their receptors. A characteristic cluster upregulated in the EPO-R and EPO-W/O groups and downregulated in the EPO-H group was identified that contained various cytokines and growth factors, including IL-6, GM-CSF, vascular endothelial growth factor B, IL-9, IL-3, leukemia inhibitory factor, and interferon alpha-2, and such receptors as thrombopoietin receptor, IL-9 receptor, and colony-stimulating factor 1 receptor. CONCLUSION These data suggest that the cross-talk network or autocrine/paracrine regulatory loop is critically impaired in BFU-E-derived cells in EPO-H patients, and investigation of these cluster genes would facilitate the development of novel therapeutic strategies for such patients.
Collapse
Affiliation(s)
- Kazushi Nakao
- Department of Medicine and Clinical Science, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Abstract
Mortality rates remain high in the United States for people who depend on artificial kidney replacement for their existence, and the mortality rates are similar in men and women. However, women differ from men in many respects; some of these ways may have an impact on the response to dialysis through mechanisms that need to be further explored. Observational studies have shown that women respond more readily to a higher dose of dialysis, and recent data from the HEMO clinical trial suggest that women respond to an increase in clearance of low-molecular-weight uremic toxins, whereas men do not. If the findings of these studies prove to be accurate, then we may conclude not only that women require a higher dose of dialysis as currently measured, but we might also expect women to require dialysis sooner during the course of a progressive decline in renal function. The reason for this gender-dependent difference in susceptibility escapes definition at the present time, but size is an obvious confound that can be explored by using current data and in future studies. More detailed analyses of the HEMO data are forthcoming and may shed further light on this question.
Collapse
Affiliation(s)
- Thomas A Depner
- Division of Nephrology, University of California, Davis, Sacramento, CA 95817, USA.
| |
Collapse
|
46
|
Merello Godino JI, Rentero R, Orlandini G, Marcelli D, Ronco C. Results from EuCliD (European Clinical Dialysis Database): impact of shifting treatment modality. Int J Artif Organs 2002; 25:1049-60. [PMID: 12487392 DOI: 10.1177/039139880202501103] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The use of biocompatible high-flux membranes is more efficient than low-flux membranes in controlling a number of hemodialysis-related diseases. The aim of this cooperative study was to evaluate the 6-month effect of a switch from low- to high-flux dialysers on patients treated in 39 Spanish dialysis centres. METHODS The clinical data used in this analysis were prospectively collected by the EuCliD database, developed to monitor the quality of treatment delivered in a large network of European Dialysis Centres. Inclusion criteria for the study were the condition of end-stage renal disease (ESRD) on chronic hemodialysis and low-flux dialysis for at least six months before the switch to high-flux dialysis. Of 1,543 patients enrolled in the study between 2000 and 2001, 1,046 patients were considered for the analysis. 497 patients were excluded because they did not complete the follow-up. Outcome measures were the reduction of pre-dialysis beta-2 microglobulin, the improvement of anemia or reduction in rHu-EPO dose required to maintain best correction of anemia, reduction of inflammatory parameters (CRP), improvement in lipid profile (Total and HDL cholesterol, tryglycerides), maintenance of nutritional status. Albumin and "dry" (post-hemodialysis) body weight were both evaluated as nutritional indexes. RESULTS During the six months of high-flux hemodialysis, there was a significant increase in hemoglobin (from 11.55 +/- 1.41 to 11.88 +/- 1.43 g/L; p < 0.001). Considering the temporarily untreated patients on a 0 U/week dose, erythropoietin remained stable (from 5,670 +/- 4,199 to 5,657 +/- 4,411 U/week). During the second part of the follow-up, the lipid profile significantly improved (Fig. 3). Total cholesterol and triglycerides decreased significantly (p < 0.001), while HDL cholesterol increased (p = 0.006). Calculated levels of LDL cholesterol also significantly decreased (p = 0.001). Dry body weight remained stable (64.7 +/- 11.9 vs. 64.7 +/- 12.0 kg) as well as in albumin levels (3.93 +/- 0.43 vs. 3.94 +/- 0.43 g/dL) between the two modalities of treatment. The level of beta2-microglobulin significantly decreased during high-flux dialysis (33.5 +/- 14.4 vs. 26.3 +/- 8.6 mg/dL, p < 0.001). CONCLUSION All above mentioned results may have as a common denominator an improved blood purification from uremic toxins and a reduced level of chronic sub-clinical inflammation. All together, these results seem to confirm the superiority of high-flux dialysis in terms of clinical and physiological outcomes.
Collapse
|
47
|
Locatelli F, Del Vecchio L, Andrulli S. The modality of dialysis treatment: does it influence the response to erythropoietin treatment? Nephrol Dial Transplant 2001; 16:1971-4. [PMID: 11572880 DOI: 10.1093/ndt/16.10.1971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
48
|
Sherman RA. Briefly Noted. Semin Dial 2001. [DOI: 10.1046/j.1525-139x.2001.00074.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|