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. 2020 May 1;13(5):821-827.
doi: 10.1093/ckj/sfaa054. eCollection 2020 Oct.

Contemporary management of anaemia, erythropoietin resistance and cardiovascular risk in patients with advanced chronic kidney disease: a nationwide analysis

Marie Evans  1 , Hannah Bower  2 , Elinor Cockburn  3 , Stefan H Jacobson  4 , Peter Barany  1   5 , Juan-Jesus Carrero  2
Affiliations

Contemporary management of anaemia, erythropoietin resistance and cardiovascular risk in patients with advanced chronic kidney disease: a nationwide analysis

Marie Evans et al. Clin Kidney J. .

Abstract

Background: Optimal management of chronic kidney disease (CKD) anaemia remains controversial and few studies have evaluated real-world management of anaemia in advanced CKD in the context of guideline recommendations.

Methods: We performed an observational study from the Swedish Renal Registry evaluating the epidemiology and treatment patterns of anaemia across Stages 3b-5 in non-dialysis (ND) and dialysis-dependent (DD) CKD patients during 2015. Logistic regression and Cox models explored the associations between anaemia treatments, inflammation, erythropoietin resistance index (ERI) and subsequent 1-year risk of major adverse cardiovascular events (MACEs).

Results: Data from 14 415 (ND, 11 370; DD, 3045) patients were included. Anaemia occurred in 60% of ND and 93% of DD patients. DD patients used more erythropoiesis-stimulating agents (ESAs; 82% versus 24%) and iron (62% versus 21%) than ND patients. All weekly ESA doses were converted to a weight-adjusted weekly epoetin equivalent dose. The prescribed ESA doses were low to moderate [median 48.2 IU/kg/week (ND), 78.6 IU/kg/week (DD)]. Among ESA-treated patients, 6-21% had haemoglobin (Hb) >13 g/dL and 2-6% had Hb <9 g/dL. Inflammation (C-reactive protein >5 mg/L) was highly prevalent and associated with ERI and higher ESA doses. Higher (>88 IU/kg/week) versus lower (<44 IU/kg/week) ESA doses were associated with a higher risk of MACEs [{ND hazard ratio [HR] 1.36 [95% confidence interval (CI) 1.00-1.86]; DD HR 1.60 [95% CI 1.24-2.06]}. There was no association between iron use and inflammation or MACEs.

Conclusions: Anaemia remains highly prevalent in advanced CKD. Patients with anaemia received moderate ESA doses with a relatively low prevalence of iron use. Higher doses of ESA were associated with inflammation and a higher risk of MACE.

Keywords: ESA; anaemia; chronic kidney disease; dialysis; epidemiology; haemoglobin; inflammation; iron.

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Figures

FIGURE 1
FIGURE 1
Flow chart of the study population. aIncluded patients with Hb levels <13 g/dL (males) or <12 g/dL (females) and those treated with ESAs.
FIGURE 2
FIGURE 2
Prevalence of anaemia [included patients with Hb levels <13 g/dL (males) or <12 g/dL (females) and those treated with ESAs] and the proportion of patients receiving ESA and iron treatment by CKD Stages 3b–5 and on dialysis.
FIGURE 3
FIGURE 3
Prevalence of concomitant iron use in ESA-treated patients by CKD Stages 3b–5 (ND patients) or dialysis type (PD and HD patients). Percentages may not add up to 100 due to rounding.
FIGURE 4
FIGURE 4
Dose of ESA by CKD stage (ND patients) or dialysis type (DD patients). Percentages may not add up to 100 due to rounding.
FIGURE 5
FIGURE 5
Distribution of Hb levels in ESA-treated patients. Percentages may not add up to 100 due to rounding.
FIGURE 6
FIGURE 6
Distribution of Hb levels in patients with body weight–adjusted ESA doses in the upper, middle and lower equivalent tertiles. Percentages may not add up to 100 due to rounding.
FIGURE 7
FIGURE 7
ESA dose per kilogram stratified by hs-CRP levels in ESA-treated ND and DD patients.
See this image and copyright information in PMC

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