Interpretation of erythropoietin levels in patients with various degrees of renal insufficiency and anemia

Fehr, Thomas; Ammann, Peter; Garzoni, Daniela; Korte, Wolfgang; Fierz, Walter; Rickli, Hans; Wüthrich, Rudolf P.

doi:10.1111/j.1523-1755.2004.00880.x

Cited by 86 publications

(86 citation statements)

References 18 publications

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“…Fehr et al (9) first suggested that it began below a GFR of 40 ml/min per 1.73 m 2 , but they did not stratify the analysis by anemia status. In this study, we examined the interaction between Hb and GFR according to anemia status and found a slightly lower GFR threshold in patients with anemia (30 ml/min per 1.73m 2 ); this is likely explained by the use of Cockcroft-Gault estimated GFR in the study by Fehr et al (9), whereas we used mGFR.…”

Section: Discussionmentioning

confidence: 99%

“…In patients without CKD, EPO and hemoglobin (Hb) levels are negatively correlated, a feedback regulation that tends to be reversed in CKD patients. (7)(8)(9) In ESRD patients, the feedback regulation process is blunted, even though it is somewhat preserved after hemorrhage (10,11) and possibly at high altitudes (12). EPO levels remain in the normal range in CKD patients compared with non-anemic healthy controls (7,13,14).…”

Section: Introductionmentioning

confidence: 99%

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Timing and Determinants of Erythropoietin Deficiency in Chronic Kidney Disease

Mercadal

Metzger

Casadevall

et al. 2012

Clinical Journal of the American Society of Nephrology

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on behalf of the NephroTest Study Group Summary Background and objectives Anemia in patients with CKD is highly related to impaired erythropoietin (EPO) response, the timing and determinants of which remain unknown.Design, setting, participants, & measurements This study measured EPO levels and studied their relation to GFR measured by 51Cr-EDTA renal clearance (mGFR) in 336 all-stage CKD patients not receiving any erythropoiesis-stimulating agent.Results In patients with anemia defined by World Health Organization criteria (hemoglobin [Hb] ,13 g/dl in men and 12 g/dl in women), EPO response to Hb level varied by mGFR level. EPO and Hb levels were negatively correlated (r=20.22, P=0.04) when mGFR was .30 ml/min per 1.73 m 2 , whereas they were not correlated when mGFR was ,30 (r=0.09, P=0.3; P for interaction=0.01). In patients with anemia, the ratio of observed EPO to the level predicted by the equation for their Hb level decreased from 0.72 (interquartile range, 0.57-0.95) for mGFR $60 ml/min per 1.73 m 2 to 0.36 (interquartile range, 0.16-0.69) for mGFR ,15. Obesity, diabetes with nephropathy other than diabetic glomerulopathy, absolute iron deficiency, and high C-reactive protein concentrations were associated with increased EPO levels, independent of Hb and mGFR.Conclusions Anemia in CKD is marked by an early relative EPO deficiency, but several factors besides Hb may persistently stimulate EPO synthesis. Although EPO deficiency is likely the main determinant of anemia in patients with advanced CKD, the presence of anemia in those with mGFR .30 ml/min per 1.73 m 2 calls for other explanatory factors.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Timing and Determinants of Erythropoietin Deficiency in Chronic Kidney Disease

Mercadal

Metzger

Casadevall

et al. 2012

Clinical Journal of the American Society of Nephrology

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“…Serum erythropoietin deficiency is often relative and, in advanced CKD, usually does not correlate with the degree of anemia (84,85). Even in patients with kidney failure treated with dialysis, the ability to upregulate erythropoietin production in response to acute anemia is preserved (86,87).…”

Section: Other Selected Recommendations Under Considerationmentioning

confidence: 99%

Critical and Honest Conversations

Williams¹,

Dwyer²,

Eddy³

et al. 2012

Clinical Journal of the American Society of Nephrology

163

115

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SummaryEstimates suggest that one third of United States health care spending results from overuse or misuse of tests, procedures, and therapies. The American Board of Internal Medicine Foundation, in partnership with Consumer Reports, initiated the "Choosing Wisely" campaign to identify areas in patient care and resource use most open to improvement. Nine subspecialty organizations joined the campaign; each organization identified five tests, procedures, or therapies that are overused, are misused, or could potentially lead to harm or unnecessary health care spending. Each of the American Society of Nephrology's (ASN's) 10 advisory groups submitted recommendations for inclusion. The ASN Quality and Patient Safety Task Force selected five recommendations based on relevance and importance to individuals with kidney disease.Recommendations selected were: (1) Do not perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms; (2) do not administer erythropoiesis-stimulating agents to CKD patients with hemoglobin levels ‡10 g/dl without symptoms of anemia; (3) avoid nonsteroidal anti-inflammatory drugs in individuals with hypertension, heart failure, or CKD of all causes, including diabetes; (4) do not place peripherally inserted central catheters in stage 3-5 CKD patients without consulting nephrology; (5) do not initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.These five recommendations and supporting evidence give providers information to facilitate prudent care decisions and empower patients to actively participate in critical, honest conversations about their care, potentially reducing unnecessary health care spending and preventing harm.

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“…Endogenous EPO is mainly of renal origin. The concentration of the hormone is abnormally low when related to the hemoglobin level ([Hb]) in CKD [43]. The anemia in CKD patients is often aggravated due to accompanying inflammatory processes, reduced iron availability, hemolysis, blood losses, nutritional deficiencies, and hyperparathyroidism [44].…”

Section: Clinical Use Of Rheposmentioning

confidence: 99%

Biosimilar epoetins and other “follow‐on” biologics: Update on the European experiences

Jelkmann¹

2010

American J Hematol

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After the patents of biopharmaceuticals have expired, based on specific regulatory approval pathways copied products (“biosimilars” or “follow‐on biologics”) have been launched in the EU. This article summarizes experiences with hematopoietic medicines, namely the epoetins (two biosimilars traded under five different brand names) and the filgrastims (two biosimilars, six brand names). Physicians and pharmacists should be familiar with the legal and pharmacological specialities of biosimilars: The production process can differ from that of the original, clinical indications can be extrapolated, glycoproteins contain varying isoforms, the formulation may differ from the original, and biopharmaceuticals are potentially immunogenic. Only on proof of quality, efficacy and safety, biosimilars are a viable option because of their lower costs. Am. J. Hematol. 2010. © 2010 Wiley‐Liss, Inc.

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Interpretation of erythropoietin levels in patients with various degrees of renal insufficiency and anemia

Cited by 86 publications

References 18 publications

Timing and Determinants of Erythropoietin Deficiency in Chronic Kidney Disease

Timing and Determinants of Erythropoietin Deficiency in Chronic Kidney Disease

Critical and Honest Conversations

Biosimilar epoetins and other “follow‐on” biologics: Update on the European experiences

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