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

Author:

Evans Marie1ORCID,Bower Hannah2,Cockburn Elinor3,Jacobson Stefan H4,Barany Peter15,Carrero Juan-Jesus2

Affiliation:

1. Department of Renal Medicine, Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden

2. Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden

3. Medical Affairs, Nordic Operations, Astellas Pharma A/S, Kastrup, Denmark

4. Department of Clinical Sciences, Division of Nephrology, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden

5. Pediatric Nephrology, Karolinska University Hospital, Stockholm, Sweden

Abstract

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.

Funder

Astellas Pharma to the Karolinska Institutet

OPEN Health Medical Communications

Publisher

Oxford University Press (OUP)

Subject

Transplantation,Nephrology

Reference34 articles.

1. Mechanisms of anemia in CKD;Babitt;J Am Soc Nephrol,2012

2. Kidney Disease: Improving Global Outcomes CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease;Kidney Int Suppl,2013

3. Influence of target hemoglobin in dialysis patients on morbidity and mortality;Collins;Kidney Int Suppl,2002

4. The effects of higher hemoglobin levels on mortality and hospitalization in hemodialysis patients;Ofsthun;Kidney Int,2003

5. Congestive heart failure in renal transplant recipients: risk factors, outcomes, and relationship with ischemic heart disease;Rigatto;J Am Soc Nephrol,2002

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