From the Guidelines
Patients on high-dose Erythropoiesis-Stimulating Agents (ESAs) are at increased risk of hypertension and thrombotic events, and therefore, careful monitoring of blood pressure and thrombotic risk factors is essential. The use of ESAs has been associated with an increased risk of thrombosis, including arterial and venous events, with a relative risk ranging from 48% to 69% compared to control patients 1. Additionally, patients with previous risk factors for thrombosis, such as hypertension, may be at higher risk for thrombosis with the use of ESAs 1.
Some key points to consider when managing patients on high-dose ESAs include:
- Evaluating the risk factors for thrombosis, such as history of thromboembolism, heritable mutation, hypercoagulability, elevated prechemotherapy platelet counts, recent surgery, hormonal agents, and comorbidities such as hypertension 1
- Monitoring hemoglobin levels regularly to avoid excessive increases in hemoglobin, which may increase the risk of thrombotic events 1
- Adjusting ESA doses based on hemoglobin response and iron status to minimize the risk of thrombosis and other adverse events 1
- Considering alternative treatments, such as hypoxia-inducible factor (HIF) stabilizers, for patients with chronic kidney disease who are on high-dose ESAs with inadequate response [@Example@]
It is essential to weigh the benefits and risks of ESA therapy in patients with cancer and chronic kidney disease, and to carefully monitor patients for signs and symptoms of thromboembolism and other adverse events 1. By taking a careful and individualized approach to ESA therapy, healthcare providers can help minimize the risks associated with these agents and optimize patient outcomes.
From the Research
Risks of Hypertension for Patients on High Dose Erythropoiesis-Stimulating Agents (ESA)
- The use of high-dose ESA therapy has been associated with increased risks of adverse outcomes, including cardiovascular events and mortality 2, 3.
- A metaregression analysis found that higher ESA doses were associated with increased all-cause mortality, cardiovascular events, and hypertension 2.
- A retrospective study found that high-dose ESA therapy was associated with increased all-cause mortality and a negative correlation between ESA dose and hemoglobin levels 3.
- The mechanism by which ESA dose affects mortality risk is unclear, but it may be related to the elevated ESA dosage required to target hemoglobin levels or underlying morbid conditions that lead to ESA resistance 3.
Cardiovascular Risks
- Higher ESA doses have been associated with increased rates of hypertension, stroke, and thrombotic events, including dialysis vascular access-related thrombotic events 2.
- However, an observational study found that ESA use was not associated with an excess of thrombotic events, including ischemic stroke, myocardial infarction, and venous thromboembolism 4.
- The relationship between ESA dose and cardiovascular risk is complex and may depend on various factors, including patient characteristics, ESA molecule used, and target hemoglobin level 5.
ESA Dose and Mortality Risk
- Higher ESA doses have been consistently associated with increased mortality risk, independent of hemoglobin level 2, 3.
- The use of high-dose ESA therapy may be associated with a higher risk of cardiovascular complications, including hypertension, stroke, and thrombotic events 2.
- Further research is needed to fully understand the relationship between ESA dose and mortality risk and to determine the optimal ESA dosing strategy for patients with chronic kidney disease 5.