Background Anemia (characterized by a hematocrit of 30 percentor lower) persists in 40 to 60 percent of patients treated forend-stage renal disease with maintenance hemodialysis, despiteconcomitant erythropoietin (epoetin) therapy. We tested thehypothesis that inadequate dialysis is a key reason for theinsufficient response to erythropoietin in patients with end-stagerenal disease who are receiving hemodialysis.
Methods we prospectively studied 135 randomly selected patientsundergoing hemodialysis who had been receiving intravenous erythropoietinfor at least four months. The adequacy of dialysis was assessedby measuring the percent reduction in the blood urea nitrogenconcentration and the serum albumin concentration. The hematocritwas measured weekly for four weeks, transferrin saturation wasmeasured, and coexisting illnesses were documented. To determinethe effect of an increased level of dialysis on the hematocrit,the thrice-weekly schedule of dialysis was increased to raisethe mean urea-reduction value from 60.7 to 72.0 percent forsix weeks in 20 consecutive patients whose base-line urea-reductionvalue was less than 65 percent. The change in the hematocritin these patients was compared with that observed in the next20 patients who had an equivalent base-line urea-reduction valuebut whose level of dialysis was not altered.
Results The mean (±SD) hematocrit of the entire groupwas 29.2±4 percent, and the mean thrice-weekly dose oferythropoietin was 59±29 U per kilogram of body weight.The mean serum albumin concentration was 3.8±0.4 g perdeciliter, the mean urea-reduction value was 62±4.8 percent,and the mean transferrin saturation was 20±9 percent.Multiple regression analysis revealed direct correlations betweenthe hematocrit and the serum albumin concentration (P = 0.009)and between the hematocrit and the urea-reduction value (P =0.012) after adjustment for other factors. A logistic-regressionanalysis indicated that an 11 percent increase in the urea-reductionvalue doubled the odds that a patient would have a hematocritabove 30 percent. After six weeks of increased intensity ofdialysis in 20 patients with base-line urea-reduction valuesof less than 65 percent, the mean (±SE) hematocrit rosefrom 28.4±0.78 percent to 32.3±0.71 percent (P= 0.002); there was no significant change in a control groupof 20 patients with equivalent base-line urea-reduction valuesin whom the dialysis level was not altered (28.2±0.84percent to 26.3±0.85 percent; P = 0.175).
Conclusions In patients with end-stage renal disease, inadequatehemodialysis is associated with a suboptimal response to erythropoietintherapy. Increasing the intensity of dialysis in patients withanemia who are receiving inadequate dialysis results in a significantincrease in the hematocrit.
Source Information
From the Renal Disease Division, Department of Medicine (O.I., E.A.F.), and the Department of Preventive Medicine and Community Health (J.F.), State University of New York Health Science Center, Brooklyn.
Address reprint requests to Dr. Ifudu at the Renal Disease Division, Box 52, Department of Medicine, SUNY Health Science Center, 450 Clarkson Ave., Brooklyn, NY 11203.
Intensity of Hemodialysis and Response to Erythropoietin
Ureña P., Petrover M., Levin N. W., Gotch F., Malhotra D., Tzamaloukas A. H., Ballinger A. B., Fairclough P. D., Clark M. L., Farthing M. J.G., Kotanko P., Ifudu O., Feldman J., Friedman E. A.
Extract |
Full Text
N Engl J Med 1996;
334:1669-1671, Jun 20, 1996.
Correspondence
This article has been cited by other articles:
Chan, C. T., Liu, P. P., Arab, S., Jamal, N., Messner, H. A
(2009). Nocturnal Hemodialysis Improves Erythropoietin Responsiveness and Growth of Hematopoietic Stem Cells. J. Am. Soc. Nephrol.
20: 665-671
[Abstract][Full Text]
Kalantar-Zadeh, K., Aronoff, G. R.
(2009). Hemoglobin Variability in Anemia of Chronic Kidney Disease. J. Am. Soc. Nephrol.
20: 479-487
[Abstract][Full Text]
Ishani, A., Solid, C. A., Weinhandl, E. D., Gilbertson, D. T., Foley, R. N., Collins, A. J.
(2008). Association between number of months below K/DOQI haemoglobin target and risk of hospitalization and death. Nephrol Dial Transplant
23: 1682-1689
[Abstract][Full Text]
Taneja, S., Mandayam, S., Kayani, Z. Z., Kuo, Y.-F., Shahinian, V. B.
(2007). Comparison of Stage at Diagnosis of Cancer in Patients Who Are on Dialysis versus the General Population. CJASN
2: 1008-1013
[Abstract][Full Text]
Chou, S. H., Tonelli, M., Bradley, J. S., Gourishankar, S., Hemmelgarn, B. R., for the Alberta Kidney Disease Network,
(2006). Quality of Care among Aboriginal Hemodialysis Patients. CJASN
1: 58-63
[Abstract][Full Text]
Dar Santos, A. E, Shalansky, K. F, Jastrzebski, J. P
(2003). Management of Anemia in Erythropoietin-Resistant Hemodialysis Patients. The Annals of Pharmacotherapy
37: 1768-1773
[Abstract][Full Text]
Krieter, D. H., Canaud, B.
(2003). High permeability of dialysis membranes: what is the limit of albumin loss?. Nephrol Dial Transplant
18: 651-654
[Full Text]
Coladonato, J. A., Frankenfield, D. L., Reddan, D. N., Klassen, P. S., Szczech, L. A., Johnson, C. A., Owen, W. F. Jr.
(2002). Trends in Anemia Management among US Hemodialysis Patients. J. Am. Soc. Nephrol.
13: 1288-1295
[Abstract][Full Text]
Goicoechea, M., Caramelo, C., Rodriguez, P., Verde, E., Gruss, E., Albalate, M., Ortiz, A., Casado, S., Valderrabano, F.
(2001). Role of type of vascular access in erythropoietin and intravenous iron requirements in haemodialysis. Nephrol Dial Transplant
16: 2188-2193
[Abstract][Full Text]
Locatelli, F., Vecchio, L. D., Andrulli, S.
(2001). The modality of dialysis treatment: does it influence the response to erythropoietin treatment?. Nephrol Dial Transplant
16: 1971-1974
[Full Text]
Basile, C., Giordano, R., Montanaro, A., Maio, P. D., Padova, F. D., Marangi, A. L., Semeraro, A.
(2001). Effect of acetate-free biofiltration on the anaemia of haemodialysis patients: a prospective cross-over study. Nephrol Dial Transplant
16: 1914-1919
[Abstract][Full Text]
Fourtounas, C., Kopelias, I., Dimitriadis, G., Agroyannis, B., Locatelli, F., Andrulli, S.
(2001). The impact of dialyzers on the anaemia of haemodialysis patients. Nephrol Dial Transplant
16: 1077-1078
[Full Text]
Sala, E., Noyszewski, E. A., Campistol, J. M., Marrades, R. M., Dreha, S., Torregrossa, J. V., Beers, J. S., Wagner, P. D., Roca, J.
(2001). Impaired muscle oxygen transfer in patients with chronic renal failure. Am. J. Physiol. Regul. Integr. Comp. Physiol.
280: R1240-R1248
[Abstract][Full Text]
Weiss, L. G., Clyne, N., Fihlho, J. D., Frisenette-Fich, C., Kurkus, J., Svensson, B.
(2000). The efficacy of once weekly compared with two or three times weekly subcutaneous epoetin {beta}: results from a randomized controlled multicentre trial. Nephrol Dial Transplant
15: 2014-2019
[Abstract][Full Text]
WARD, R. A., SCHMIDT, B., HULLIN, J., HILLEBRAND, G. F., SAMTLEBEN, W.
(2000). A Comparison of On-Line Hemodiafiltration and High-Flux Hemodialysis: A Prospective Clinical Study. J. Am. Soc. Nephrol.
11: 2344-2350
[Abstract][Full Text]
Eckardt, K.-U.
(2000). Anaemia correction--does the mode of dialysis matter?. Nephrol Dial Transplant
15: 1278-1280
[Full Text]
Locatelli, F., Andrulli, S., Pecchini, F., Pedrini, L., Agliata, S., Lucchi, L., Farina, M., La Milia, V., Grassi, C., Borghi, M., Redaelli, B., Conte, F., Ratto, G., Cabiddu, G., Grossi, C., Modenese, R.
(2000). Effect of high-flux dialysis on the anaemia of haemodialysis patients. Nephrol Dial Transplant
15: 1399-1409
[Abstract][Full Text]
Locatelli, F., Valderrabano, F., Hoenich, N., Bommer, J., Leunissen, K., Cambi, V.
(2000). Progress in dialysis technology: membrane selection and patient outcome. Nephrol Dial Transplant
15: 1133-1139
[Full Text]
BESARAB, A., FRINAK, S., YEE, J.
(1999). An Indistinct Balance: The Safety and Efficacy of Parenteral IronTherapy. J. Am. Soc. Nephrol.
10: 2029-2043
[Full Text]
Ifudu, O.
(1998). Care of Patients Undergoing Hemodialysis. NEJM
339: 1054-1062
[Full Text]
Kaufman, J. S., Reda, D. J., Fye, C. L., Goldfarb, D. S., Henderson, W. G., Kleinman, J. G., Vaamonde, C. A., The Department of Veterans Affairs Cooperative Stu,
(1998). Subcutaneous Compared with Intravenous Epoetin in Patients Receiving Hemodialysis. NEJM
339: 578-583
[Abstract][Full Text]
Cazzola, M., Mercuriali, F., Brugnara, C.
(1997). Use of Recombinant Human Erythropoietin Outside the Setting of Uremia. Blood
89: 4248-4267
[Full Text]
Urena, P., Petrover, M., Levin, N. W., Gotch, F., Malhotra, D., Tzamaloukas, A. H., Ballinger, A. B., Fairclough, P. D., Clark, M. L., Farthing, M. J.G., Kotanko, P., Ifudu, O., Feldman, J., Friedman, E. A.
(1996). Intensity of Hemodialysis and Response to Erythropoietin. NEJM
334: 1669-1671
[Full Text]
Lacombe, C.
(1996). Resistance to Erythropoietin. NEJM
334: 660-662
[Full Text]
Klahr, S.
(1996). Anemia, Dialysis, and Dollars. NEJM
334: 461-463
[Full Text]
Previous
