From the Guidelines
A patient who experienced anaphylaxis to albumin is not the correct answer, instead, an absolute contraindication to the use of Erythropoiesis Stimulating Agents (ESAs) in a patient with anemia of Chronic Kidney Disease (CKD) is a history of pure red cell aplasia (PRCA) that developed following treatment with any erythropoietin product, as stated in the clinical practice guidelines for evidence-based use of erythropoietic-stimulating agents 1. When considering the use of ESAs in patients with anemia of CKD, it is crucial to evaluate the potential risks and benefits, particularly in relation to absolute contraindications.
- Key points to consider include:
- Pure red cell aplasia (PRCA) is a rare but severe adverse effect of ESA therapy, characterized by the production of neutralizing antibodies to erythropoietin molecules, leading to a lack of effective erythropoietin receptor stimulation and severe anemia 1.
- The development of PRCA is a potential risk with all ESA therapies, with an incidence of about 0.5 case per 10,000 patient years’ exposure, particularly after subcutaneous exposure 1.
- If PRCA is confirmed, all ESA therapies should be stopped, and consideration should be given to immunosuppressive therapy or renal transplantation 1.
- Other absolute contraindications to ESA therapy may include known hypersensitivity to ESAs or their components and active malignancy where cure is not the intent of therapy. In the context of the provided options,
- Hemoglobin < 10g/dL is not an absolute contraindication to ESA therapy, as ESAs are often used to treat anemia in patients with CKD.
- A patient taking concomitant iron supplementation is not a contraindication to ESA therapy, as iron supplementation is often necessary to support erythropoiesis in patients with anemia of CKD.
- Hypotension is not typically considered an absolute contraindication to ESA therapy, although caution should be exercised in patients with cardiovascular disease or those at risk of hypotension. It is essential to carefully evaluate each patient's individual risk factors and medical history before initiating ESA therapy, prioritizing their morbidity, mortality, and quality of life outcomes.
From the Research
Absolute Contraindications to Erythropoiesis Stimulating Agents (ESAs)
The following are potential absolute contraindications to the use of ESAs in patients with anemia of Chronic Kidney Disease (CKD):
- A patient who experienced anaphylaxis to albumin 2 Other options are not absolute contraindications:
- Hemoglobin < 10g/dL is not an absolute contraindication, as ESAs can be used to increase hemoglobin levels in patients with anemia of CKD 3, 4, 5
- A patient taking concomitant iron supplementation is not an absolute contraindication, as iron supplementation is often used in conjunction with ESAs to manage anemia in CKD patients 3, 4, 5
- Hypotension is not an absolute contraindication, although it may be a consideration in the management of patients with CKD and anemia 6
Key Considerations
When considering the use of ESAs in patients with anemia of CKD, it is essential to evaluate the potential benefits and risks, including the risk of cardiovascular events and the need for regular monitoring of hemoglobin levels and iron status 3, 4, 6, 5, 2.