ESAs in Dialysis Patients

Singh, Ajay K.

doi:10.1681/asn.2010020178

Cited by 14 publications

(7 citation statements)

References 28 publications

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“…However, high doses of ESA should always be avoided in both CKD and CHF even if this means leaving the Hb lower. Some would argue that a target Hb of 10-12 g/dl is currently sufficient for CKD [30,31]. 12.…”

Section: Introductionmentioning

confidence: 99%

The role of erythropoiesis stimulating agents and intravenous (IV) iron in the cardio renal anemia syndrome

Silverberg¹

2010

Heart Fail Rev

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Anemia is common in Congestive Heart Failure (CHF) and is associated with an increased mortality, morbidity and progressive renal failure. The most common causes of the anemia in CHF are (1) the associated Chronic Kidney Disease (CKD), which causes depression of erythropoietin (EPO) production in the kidney, and (2) excessive cytokine production in CHF, which can cause both depression of erythropoietin production in the kidney and depression of erythropoietin response in the bone marrow. The cytokines can also induce iron deficiency by increasing hepcidin production from the liver, which both reduces gastrointestinal iron absorption and reduces iron release from iron stores located in the macrophages and hepatocytes. It appears that iron deficiency is very common in CHF and is rarely recognized or treated. The iron deficiency can cause a thrombocytosis that might contribute to cardiovascular complications in both CHF and CKD and is reversible with iron treatment. Thus, attempts to control this anemia in CHF will have to take into consideration both the use of both Erythropoiesis Stimulating Agents (ESA) such as EPO and oral and, probably more importantly, intravenous (IV) iron. Many studies of anemia in CHF with ESA and oral or IV iron and even with IV iron without ESA have shown a positive effect on hospitalization, New York Heart Association functional class, cardiac and renal function, quality of life, exercise capacity and reduced Beta Natriuretic Peptide and have not demonstrated an increase in cardiovascular damage related to the therapy. However, adequately powered long-term placebo-controlled studies of ESA and of IV iron in CHF are still needed and are currently being carried out.

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Section: Introductionmentioning

confidence: 99%

The role of erythropoiesis stimulating agents and intravenous (IV) iron in the cardio renal anemia syndrome

Silverberg¹

2010

Heart Fail Rev

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“…Furthermore, CMS, in its "Triple Aim," emphasizes the importance of improving the patient's experience of care, which acknowledges that the uniform application of evidence-based medicine must be tempered by the response of the patient, both physically and emotionally. A similar individualized treatment approach has been encouraged in the management of anemia with erythropoietin stimulating agents (ESA) in both CKD and dialysis patients (4). In the anemia arena it has been suggested that instead of focusing solely on hemoglobin values, focus should be placed on a patient's anemia-related symptoms while being mindful of the risks and benefits of ESAs (5).…”

Section: Individual Patient Contextmentioning

confidence: 99%

Re-envisioning Fistula First in a Patient-Centered Culture

Gomes

Schmidt

Wish

2013

Clinical Journal of the American Society of Nephrology

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SummaryThe main options for vascular access in hemodialysis patients are arteriovenous fistulas (AVFs), arteriovenous grafts, and tunneled cuffed central venous catheters. AVFs have the lowest complication rate and require the fewest interventions and lowest cost to maintain. There has been a dramatic national increase in prevalent AVFs among patients with ESRD in the United States driven, in part, by the Fistula First Breakthrough Initiative. The Fistula First Breakthrough Initiative has engaged stakeholders in the dialysis community to disseminate best practices and quality improvement activities to increase AVF prevalence in suitable candidates. In the pursuit of maximizing AVF placement and prevalence, less emphasis has been placed on the individual patient context. An AVF may not be the best access choice in a subset of patients, particularly those with poor long-term prognoses or comorbid chronic diseases with a short life expectancy, those patients more likely to die than to have their CKD progress to ESRD requiring dialysis, and those with vascular anatomy not amenable to successful AVF placement. Placement of an AVF in these patients subjects them to uncomfortable and likely unnecessary and/or unsuccessful surgeries at an expense, while doing little to improve their clinical outcome or their individual experience of care. AVF prevalence as a pay-for-performance measure without the appropriate case-mix adjustment may penalize providers for accepting higher-risk patients. Although a functioning AVF that provides reliable hemodialysis remains the gold standard for vascular access for most patients, it may not be the most suitable option for every patient.

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“…Further controversies also derive from recent results of increased morbidity and mortality in CKD patients associated with higher hemoglobin levels [74], intensive blood pressure [75] and glucose control [76], dual angiotensin II blockade [77] and suppression of parathyroid function, and bone turnover [47, 48], which question the safety of overaggressive intervention on specific laboratory and clinical parameters in this patient group. Rather than meticulously pursuing generalised targets, recent opinions suggest a potential benefit from a more individualised perspective, that takes into account patient-specific trends and distinctive dynamic features of the actual clinical situation [66, 78, 79]. …”

Section: Cardiovascular Risk Modification In Ckdmentioning

confidence: 99%

Cardiorenal Syndrome Type 4—Cardiovascular Disease in Patients with Chronic Kidney Disease: Epidemiology, Pathogenesis, and Management

Pateinakis

Papagianni

2011

International Journal of Nephrology

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The term cardiorenal syndrome refers to the interaction between the heart and the kidney in disease and encompasses five distinct types according to the initial site affected and the acute or chronic nature of the injury. Type 4, or chronic renocardiac syndrome, involves the features of chronic renal disease (CKD) leading to cardiovascular injury. There is sufficient epidemiologic evidence linking CKD with increased cardiovascular morbidity and mortality. The underlying pathophysiology goes beyond the highly prevalent traditional cardiovascular risk burden affecting renal patients. It involves CKD-related factors, which lead to cardiac and vascular pathology, mainly left ventricular hypertrophy, myocardial fibrosis, and vascular calcification. Risk management should consider both traditional and CKD-related factors, while therapeutic interventions, apart from appearing underutilized, still await further confirmation from large trials.

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ESAs in Dialysis Patients

Cited by 14 publications

References 28 publications

The role of erythropoiesis stimulating agents and intravenous (IV) iron in the cardio renal anemia syndrome

The role of erythropoiesis stimulating agents and intravenous (IV) iron in the cardio renal anemia syndrome

Re-envisioning Fistula First in a Patient-Centered Culture

Cardiorenal Syndrome Type 4—Cardiovascular Disease in Patients with Chronic Kidney Disease: Epidemiology, Pathogenesis, and Management

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