Do we hold erythropoiesis-stimulating agent (ESA) dose in dialysis patients if hemoglobin (Hgb) is 10?

From the Guidelines

Holding the erythropoiesis-stimulating agent (ESA) dose in dialysis patients with a hemoglobin level of 10 g/dL is generally not recommended, but rather the dose should be adjusted based on the patient's individual response, iron status, and comorbidities, as well as the rate of hemoglobin change, with the goal of maintaining a target hemoglobin range of 10-11 g/dL. The decision to adjust the ESA dose should be based on the patient's clinical circumstances, including their target hemoglobin range and rate of hemoglobin change, as recommended by the KDIGO guideline on anemia 1.

Key Considerations

• The rate of hemoglobin rise is important, and dose reduction should be considered if levels are increasing rapidly (more than 1 g/dL over 2 weeks) 1.
• ESA dosing requires individualization based on the patient's response, iron status, and comorbidities, with adequate iron stores (ferritin >100 ng/mL and transferrin saturation >20%) ensured for optimal ESA response 1.
• Regular monitoring of hemoglobin levels (typically every 2-4 weeks) is necessary to guide appropriate ESA adjustments and maintain hemoglobin within the target range while avoiding excessive fluctuations 1.
• The FDA recommends that ESA therapy should not be initiated at Hb levels ≥ 10 g/dL, and it has not been demonstrated to improve symptoms of anemia, quality of life, fatigue, or patient well-being in patients with Hb levels ≥ 10 g/dL 1.

Clinical Implications

• For most dialysis patients, the recommended target hemoglobin range is typically 10-11 g/dL, as higher levels have been associated with increased cardiovascular risks without providing additional benefits.
• If the hemoglobin level is stable at 10 g/dL, the current ESA dose may be maintained, but close monitoring is essential to avoid excessive fluctuations and to adjust the dose as needed based on the patient's individual response and clinical circumstances.

From the Research

Erythropoiesis-Stimulating Agent (ESA) Dose in Dialysis Patients

• The decision to hold ESA dose in dialysis patients with a hemoglobin (Hgb) level of 10 is complex and depends on various factors, including the patient's overall health, iron stores, and ESA responsiveness 2, 3, 4.
• Studies have shown that maintaining a target Hgb range of 11-13 g/dL is difficult, and Hgb variability is common in dialysis patients, with 20.8% of laboratory values showing Hgb variation events and 14.7% showing anemia events 2.
• The 2012 Kidney Disease Improving Global Outcomes Clinical Practice Guideline for Anemia in CKD suggests avoiding ESA therapy use to maintain Hb level above 11.5 g/dL, but the optimal Hgb target range in adult patients undergoing chronic dialysis remains unknown 5.
• High doses of ESA to achieve Hgb levels greater than 13 g/dL have been associated with increased mortality, possibly due to induced iron depletion and resultant relative thrombocytosis 6.
• In patients with a Hgb level of 10, it is essential to assess iron stores, ESA responsiveness, and other factors before making decisions about ESA dose adjustments, as iron depletion can occur even with lower Hgb targets 4, 6.

Considerations for ESA Dose Adjustments

• ESA dose adjustments should be based on individual patient needs, taking into account factors such as iron stores, Hgb variability, and ESA responsiveness 2, 3, 4.
• The use of long-acting darbepoetin may achieve better Hgb stability than short-acting erythropoietin, but this should be considered in the context of individual patient needs and response to therapy 2.
• Regular monitoring of Hgb levels, iron stores, and ESA dose is crucial to ensure optimal management of anemia in dialysis patients 3, 5.