Factors Related to the Absence of Anemia in Hemodialysis Patients

Abstract

Background: A small number of hemodialysis (HD) patients have normal hemoglobin (Hb) levels without the need for erythropoiesis-stimulating agents (ESAs). The factors associated with this condition have been little studied. The objective of this prospective study was to determine these factors in a prevalent population of HD patients. Materials and Methods: All patients who had normal Hb levels and who had not received ESAs in the last 6 months (non-ESA group) were included. Epidemiological and laboratory data were collected and we performed an abdominal ultrasound to assess hepatic and renal cysts. This group was compared to a control group of 205 prevalent HD patients on ESA therapy (control group). Results: We included 45 patients (16% from the whole group) in the non-ESA group. In this group, there was a higher proportion of men (76.5 vs. 61%), patients were younger (61.1 ± 14.7 vs. 67.5 ± 15.2 years), had a longer duration of renal replacement therapy (RRT) (9.4 ± 8.3 vs. 5.3 ± 5.8 years) and had a higher prevalence of adult polycystic kidney disease (APKD) and hepatitis C virus (HCV) liver disease (42.2 vs. 10.2%), p < 0.01. In the non-ESA group, HCV+ patients had a lower prevalence of APKD (2.2 vs. 38.4%) and hepatic cysts (2.2 vs. 19.2%), but significantly higher endogenous erythropoietin levels (55.8 ± 37.1 vs. 30.9 ± 38.4 mU/ml). No significant differences in anemia, iron metabolism, insulin, IGF-1 and renin were found between non-ESA and control groups. Non-ESA patients had a significantly higher number of renal (90.6 vs. 36.5%) and hepatic cysts (12.5 vs. 3.4%), and these were also larger in size (3.3 ± 2.4 vs. 1.5 ± 0.8 cm). In the multivariate Cox analysis, independent predictor factors for absence of anemia in HD patients were number of renal cysts >10 cysts (95% CI 1.058–1.405; p = 0.00), HCV+ liver disease (95% CI 1.147–1.511; p = 0.05) and time on RRT (95% CI 1.002–1.121; p = 0.05). Conclusions: The absence of anemia in HD patients is not infrequent. Its frequency is higher in men and younger patients with long-term RRT, in patients with HCV+ liver disease and in APKD. It is associated with increased endogenous erythropoietin production and the presence of renal and hepatic cysts.

Effect of long period treatment with erythropoiesis stimulating agents on clinically and laboratory parameters in hemodialysis autosomal dominant polycystic kidney disease patients

“…Our non-ESA patients had lower values of ferritin than the ones in the ESA group, a result that matches others (2,12). TSAT was also reduced in our group, as was in another study, while others did not observe a significant difference or did not find TSAT values as predictive factors for non-ESA status (2,3,12). The study by Gaweda et al analyzed how ferritin and TSAT values influence Hb increase after ESA therapy in patients on HD.…”

“…Other studies did not find a significant difference in Kt/V and it was not a predictive factor for non-ESA status (2,3). In a group of 68 HD patients, Kt/V did not correlate with hematocrit but a significant inverse association between Kt/V and ESA dose was observed.…”

“…The absence of anemia may be related, in part, to a higher capacity of patients to produce erythropoietin (EPO) (2). The presence of renal or hepatic cysts was associated with increased EPO synthesis and the absence of anemia in patients on HD (3). Patients with polycystic kidney disease produce more EPO and require lower ESA doses (4).…”

Body composition affects the response to erythropoiesis-stimulating agents in patients with chronic kidney disease in dialysis

“…As was reported in our previous study, this situation of a clinically unstable state without inflammation and its association with certain factors such as the production of endogenous erythropoietin by liver and renal cysts and time in dialysis, is not uncommon. 22 However, although the data demonstrate an association between fat tissue and ESA, a causal explanation for this demonstration cannot be offered. We suggest an association between the hydration state and fat tissue.…”

Platelet counts in autosomal dominant polycystic kidney disease

“…Statistically lower but clinically insignificant differences in platelet counts were found in dialysis patients. However, this may be explained by the finding of higher haemoglobin and lower ESA usage in ADPKD patients on dialysis compared with controls, and this is expected due to higher endogenous EPO synthesis [3] and it is known that EPO can stimulate combined haemopoetic-megakaryocyte progenitor cells [4].…”