Abstract
Erythropoiesis-stimulating agent (ESA) responsiveness has been reported to be associated with increased mortality in hemodialysis (HD) patients. ESA requirement to obtain the same hemoglobin (Hb) level is different between HD and peritoneal dialysis (PD) patients. In this study, we investigated the impact of ESA responsiveness on mortality between both HD and PD patients. Prevalent HD and PD patients were selected from the Clinical Research Center registry for end-stage renal disease, a prospective cohort study in Korea. ESA responsiveness was estimated using an erythropoietin resistant index (ERI) (U/kg/week/g/dL). Patients were divided into three groups by tertiles of ERI. ESA responsiveness was also assessed based on a combination of ESA dosage and hemoglobin (Hb) levels. The primary outcome was all-cause mortality. A total of 1,594 HD and 876 PD patients were included. The median ESA dose and ERI were lower in PD patients compared with HD patients (ESA dose: 4000 U/week vs 6000 U/week, respectively. P<0.001, ERI: 7.0 vs 10.4 U/kg/week/g/dl, respectively. P<0.001). The median follow-up period was 40 months. In HD patients, the highest ERI tertile was significantly associated with higher risk for all-cause mortality (HR 1.96, 95% CI, 1.07 to 3.59, P = 0.029). HD patients with high-dose ESA and low Hb levels (ESA hypo-responsiveness) had a significantly higher risk of all-cause mortality (HR 2.24, 95% CI, 1.16 to 4.31, P = 0.016). In PD patients, there was no significant difference in all-cause mortality among the ERI groups (P = 0.247, log-rank test). ESA hypo-responsiveness was not associated with all-cause mortality (HR = 1.75, 95% CI, 0.58 to 5.28, P = 0.319). Our data showed that ESA hypo-responsiveness was associated with an increased risk of all-cause mortality in HD patients. However, in PD patients, ESA hypo-responsiveness was not related to all-cause mortality. These finding suggest the different prognostic value of ESA responsiveness between HD and PD patients.
Highlights
Correction of severe anemia toward the conventional hemoglobin (Hb) target level using erythropoiesis-stimulating agents (ESA) has beneficial effects on the reduction of left ventricular mass in patients with hemodialysis (HD) [1,2,3,4,5]
We investigated the impact of ESA responsiveness on all-cause mortality in the HD and peritoneal dialysis (PD) populations in the Clinical Research Center (CRC) registry for end-stage renal disease (ESRD) cohort, an observational prospective cohort study conducted in Korea
There was no significant difference in all-cause mortality among the four groups (P = 0.129, log-rank test, data not shown). In this multicenter prospective observational study performed in Korean ESRD population undergoing dialysis, we demonstrated that ESA responsiveness, calculated either by the erythropoietin resistant index (ERI) or by categorization based on combining ESA dose and Hb levels, was associated with all-cause mortality in HD patients, whereas it was not related to all-cause mortality in PD patients
Summary
Correction of severe anemia toward the conventional hemoglobin (Hb) target level using erythropoiesis-stimulating agents (ESA) has beneficial effects on the reduction of left ventricular mass in patients with hemodialysis (HD) [1,2,3,4,5]. Patients on PD have lower requirements of ESA to obtain the same Hb level, compared with patients on HD [15,16,17]. For these reasons, it may be postulated that the impact of the response to ESA treatment on mortality may differ between patients with HD and PD. Considering of international differences of trends in ESA use and Hb levels in dialysis patients [18,19], the impact of ESA responsiveness on mortality in HD and PD patients may vary among the countries and ethnic group
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