Mortality in dialysis patients may not be associated with ESA dose: a 2-year prospective observational study.

BACKGROUND: Anaemia of chronic kidney disease increases the risk of death and adverse events, but can be managed using erythropoiesis stimulating agents (ESAs). However, recent evidence suggests that targeting a higher haemoglobin concentration ([Hb]) increases mortality risk, and both higher [Hb] targets and ESA doses have been implicated. Nonetheless, a causative role has not been demonstrated, and this potential relationship requires further appraisal in such a complex patient group. METHODS: The relationship between the haematopoietic response to ESAs and patient survival in 302 stable, prevalent dialysis patients was explored in a prospective, single-centre study. Clinical and laboratory parameters influencing mortality and ESA resistance were analysed. Patients were stratified into 5 groups, according to their [Hb] and ESA dosage, and were followed for 2 years. RESULTS: Little difference in co-morbidities between groups was identified. 73 patients died and 36 were transplanted. Initial analysis suggested a direct relationship between mortality and ESA dosage. However, Cox proportional hazards multivariate analysis demonstrated mortality risk was associated only with age (adjusted HR per year: 1.061, 95% CI 1.031-1.092), dialysis duration (adjusted HR: 1.010, 95% CI 1.004-1.016), peripheral vascular disease (adjusted HR: 1.967, 95% CI 1.083-3.576) and CRP (adjusted HR: 1.024, 95% CI 1.011-1.039). Mortality was increased in patients poorly responsive to ESAs (55.5%). CONCLUSION: ESA dose does not appear to contribute substantially to mortality risk in dialysis patients. Instead, age and co-morbidities appear to be the critical determinants. A poor response to ESAs is a marker of overall poor health status.

Benefits and limitations of plasmapheresis in renal diseases: an evidence-based approach.

In use for over 50 years, the rationale for plasmapheresis remains based largely on case series and retrospective studies. Recently, results from several randomized controlled trials, meta-analyses, and prospective studies have shown plasmapheresis may be of benefit in various renal diseases, and have provided insights into more rational use of this therapy. A multicenter trial by the European Vasculitis Study Group has shown it is the preferred additional form of therapy for patients with anti-neutrophil cytoplasmic antibody-associated glomerulonephritis and severe renal failure. A recent study conducted at Mayo Clinic also found it effective at reversing renal failure from myeloma-related cast nephropathy if serum free light chain levels were reduced by at least 50%. In addition, a Cochrane review has analyzed the available evidence for its use in thrombotic thrombocytopenic purpura and hemolytic uremic syndrome. The objective of this article is to review recent and past evidence and, thereby, the current indications for treatment in renal disease.