Anemia management in cancer patients with chronic kidney disease

Abstract

Cancer and kidney disease are linked by causality and comorbidities. Observational data show an increased risk of malignancy as renal function declines. Erythropoietin stimulating agents (ESAs), which are the cornerstone therapy for anemia patients with chronic kidney disease and cancer, are associated with increased risks for cancer, cancer‐related mortality, progression of disease, and thromboembolic events. This article examines the recently published guidelines for ESA use in cancer patients from the American Society of Clinical Oncology and American Society of Hematology and attempts to contextualize them to the care of patients with coexistent CKD, cancer, and anemia.

Treatment of anemia in difficult-to-manage patients with chronic kidney disease

“…[43][44][45][46] In addition, in vitro and in vivo studies have indicated that ESAs may be involved in promoting tumor progression. [47][48][49][50][51] ESAs bind to and activate erythropoietin receptors, thereby stimulating pathways involved in cellular differentiation, proliferation, and prevention of apoptosis, including the Janus-activated 2/signal transducer and activator of transcription 5, phosphoinositide 3-kinase/protein kinase B, and Ras/extracellular signal-regulated kinase pathways. [47][48][49][50][51] Furthermore, no guidelines exist for nephrologists regarding the use of ESA therapy in anemic CKD patients with cancer.…”

“…[47][48][49][50][51] ESAs bind to and activate erythropoietin receptors, thereby stimulating pathways involved in cellular differentiation, proliferation, and prevention of apoptosis, including the Janus-activated 2/signal transducer and activator of transcription 5, phosphoinositide 3-kinase/protein kinase B, and Ras/extracellular signal-regulated kinase pathways. [47][48][49][50][51] Furthermore, no guidelines exist for nephrologists regarding the use of ESA therapy in anemic CKD patients with cancer. 52 The long-term effects of iron supplementation on clinical outcomes, including cardiovascular events, hospitalization, and mortality, as well as the safety of iron therapy in patients with cancer and CKD, are unknown.…”

Chronic Kidney Disease: Role of Diet for a Reduction in the Severity of the Disease

“…Anemia is a common consequence of CKD, especially in advanced stages; more than 50% of ESRD patients have anemia [30]. A decline of erythropoietin (EPO) production is commonly experienced [31] due to a reduction in renal function [32].…”

“…Erythropoiesis-stimulating agents (EAS) have been considered the best treatment for managing anemia in CKD patients since they became available in 1989 [30]. Although the use of ESAs has improved conditions in CKD, RCTs have questioned the safety of the duration in treatment and the use of high dose ESAs to normalize hemoglobin (Hb) levels [38].…”

“…Individualized cases include the rate of decreasing Hb, the risks of needing a transfusion, response to prior treatment, the severity of anemic symptoms, and the potential risk related to ESAs [39]. The KDIGO guidelines are only recommendations with less than satisfactory evidence; however, there are no current clear guidelines, so the KDIGO guidelines serve as a significant point of reference for clinical use when determining how or when to treat anemic CKD patients with ESAs [30].…”