Does End-Stage Renal Disease (ESRD) and dialysis affect hemoglobin levels?

From the Guidelines

Yes, end-stage renal disease (ESRD) and dialysis significantly affect hemoglobin levels, typically causing anemia.

Introduction to Anemia in ESRD

Patients with ESRD often develop anemia due to decreased erythropoietin production by the kidneys, which normally stimulates red blood cell production in the bone marrow. Additionally, uremic toxins that accumulate in ESRD can shorten red blood cell lifespan, while dialysis procedures themselves can lead to blood loss and hemolysis.

Management of Anemia

Management typically includes erythropoiesis-stimulating agents (ESAs) like epoetin alfa (starting at 50-100 units/kg three times weekly) or darbepoetin alfa (0.45 μg/kg once weekly), with dose adjustments based on hemoglobin response. Iron supplementation is also crucial, with intravenous iron (such as iron sucrose 100-200 mg or ferric gluconate 125 mg) often preferred over oral formulations due to better absorption.

Target Hemoglobin Range

The target hemoglobin range for ESRD patients is typically 11.0 to 12.0 g/dL, as recommended by the KDOQI clinical practice guideline and clinical practice recommendations for anemia in chronic kidney disease: 2007 update of hemoglobin target 1. Higher levels may increase cardiovascular risks, as evidenced by studies such as the CHOIR trial, which found that targeting a hemoglobin level of 135 g/l resulted in a higher risk of death, myocardial infarction, hospitalization for congestive heart failure, and stroke compared to targeting a level of 113 g/l 1.

Monitoring and Quality of Life

Regular monitoring of hemoglobin levels, iron studies, and transferrin saturation is essential for effective anemia management in these patients. Quality of life is also an important consideration, with studies suggesting that higher hemoglobin levels may improve quality of life, but the magnitude of these effects may diminish over time 1. Some key points to consider in the management of anemia in ESRD patients include:

• The importance of regular monitoring of hemoglobin levels and iron studies
• The need for individualized treatment plans, taking into account the patient's underlying medical conditions and response to therapy
• The potential risks and benefits of targeting higher hemoglobin levels, including the increased risk of cardiovascular events and the potential for improved quality of life.

From the FDA Drug Label

In early clinical studies conducted in patients with CKD on dialysis, ESAs have been shown to reduce the use of RBC transfusions. These studies enrolled patients with mean baseline hemoglobin levels of approximately 7. 5 g/dL and ESAs were generally titrated to achieve a hemoglobin level of approximately 12 g/dL. The safety and efficacy of PROCRIT were evaluated in 13 clinical studies involving intravenous administration to a total of 1010 patients on dialysis with anemia. Overall, more than 90% of the patients treated with PROCRIT experienced improvement in hemoglobin concentrations

ESRD and dialysis affect hemoglobin levels by reducing them, as patients with CKD on dialysis have mean baseline hemoglobin levels of approximately 7.5 g/dL.

• Hemoglobin levels can be improved with the use of ESAs, such as darbepoetin alfa and epoetin alfa, which have been shown to increase hemoglobin levels and reduce the need for RBC transfusions in patients with CKD on dialysis 2, 3.
• Target hemoglobin levels are generally around 12 g/dL, although some studies have targeted higher or lower levels 2, 2.

From the Research

ESRD and Dialysis Impact on Hemoglobin

• ESRD and dialysis can significantly affect hemoglobin levels in patients, with anemia being a common complication [(4,5,6,7)].
• The use of erythropoiesis-stimulating agents (ESAs) is a common treatment for anemia in patients with ESRD, and can help increase hemoglobin levels [(4,5,6,7,8)].
• However, ESA use can also be associated with increased risks such as hypertension, pure red cell aplasia, and cancer, and should be used judiciously [(7,8)].

Hemoglobin Levels in ESRD Patients

• Studies have shown that mean hemoglobin concentrations in ESRD patients can vary, with one study showing an increase from 9.5 g/dL in 1995 to a peak of 10.3 g/dL in 2006, before decreasing moderately to 9.9 g/dL in 2010 5.
• Another study suggested that partial, but not complete correction of renal anemia is associated with improved outcomes in patients with CKD 7.

Treatment of Anemia in ESRD Patients

• The treatment of anemia in ESRD patients often involves the use of ESAs, iron supplements, and blood transfusions [(4,5,6,7,8)].
• The goal of treatment is to maintain hemoglobin levels within a target range, typically between 10-11 g/dL 8.
• The use of HIF-PH inhibitors has also been shown to increase hemoglobin levels and reduce hepcidin in patients with anemia of CKD 4.