Extended Literature Review of the role of erythropoietin stimulating agents (ESA) use in the management of post renal transplant anaemia

Abstract

Background: Anemia is known to impact quality of life and survival in both renal and non-renal patients. End stage kidney disease (ESKD) patient's survival substantially improves post transplantation. Observational studies have reported better patients and graft outcomes in non anemic renal transplant recipients. Anemia of chronic kidney disease (CKD) is frequently linked to erythropoietin deficiency. Patients with post-transplant anemia (PTA) represent a distinct subset of CKD population. The benefit of using erythropoietin stimulating agents (ESA) in PTA is not clearly defined. Aim: The aim of this extended literature review is to define the role of ESA use in improving hemoglobin (Hb) level and graft survival in patients with PTA. Methods: An extended literature review was done to identify randomized controlled trials (RCTs) with patients with PTA as the study population, the use of erythropoietin stimulating agents as the intervention, and the renal function and Hb level as the outcomes. The aim of this literature review is to delineate the role of using ESA in PTA. Medline, Google scholar, Scopus, and CINHAL data bases were searched and papers meeting the pre-set inclusion criteria were identified. Results: A total of 163 papers were identified. After screening the results, four papers met the inclusion criteria and were included for review. 2/4 papers recruited patients with early PTA, while 2/4 papers recruited patients with late PTA. The early PTA papers were not consistent in reporting the effect of ESA in improving renal outcomes. Both studies showed that using ESA had no additional benefit in anemia treatment. 2/4 studies looked at late PTA. The study designs were similar and the follow up period was 2-3 years. Both studies showed a better graft survival in the higher Hb group. Conclusion: In the case of early PTA, the benefit of using ESA is not clear. The two RCTs studying the effect of ESA in patients with late PTA showed that targeting higher Hb levels was associated with better graft function. The optimal Hb target and the utility of intravenous iron need further clarifications.