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THERAPEUTIC CONTROVERSIES

Optimizing Anemia Management in Hospitalized Patients with End-Stage Renal Disease

Instructor, Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI

Bruce A Mueller, PharmD FCCP

Professor and Department Chair, Department of Clinical, Social and Administrative Sciences, College of Pharmacy, University of Michigan

Jonathan H Segal, MD

Assistant Professor, Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School

Reprints: Dr. Heung, Internal Medicine—Nephrology, University of Michigan, 1500 E. Medical Center Dr., 3914 Taubman Center/SPC 5364, Ann Arbor, MI 48109, fax 734/936-9621, mheung{at}umich.edu

OBJECTIVE: To review available literature on the use of erythropoiesis-stimulating agents (ESAs) in patients with end-stage renal disease (ESRD) who require hospitalization and to provide recommendations for ESA use in this setting.

DATA SOURCES: Primary articles were identified by English-language MEDLINE search (1966–October 2008) using the MeSH headings: kidney failure (chronic), anemia, erythropoietin, darbepoetin, hospitalization, and hematinics. Relevant data presented at recent nephrology scientific meetings (2004–October 2008) were also identified.

STUDY SELECTION AND DATA EXTRACTION: Identified studies were reviewed and information regarding hospitalization, ESA use, and patient outcomes was evaluated.

DATA SYNTHESIS: Studies demonstrate that hospitalized patients with ESRD usually experience a decline in hemoglobin values. Contributing factors include infection, inflammation, and untreated iron deficiency. ESAs are used inconsistently during hospitalization, with less than 50% of hospitalized patients with ESRD receiving ESA therapy in some reports. Some controversy exists regarding optimal hemoglobin targets for ESA therapy in nonhospitalized patients with ESRD, and no targets are defined for hospitalized patients. Clinical trials examining in-hospital ESA use have primarily involved the intensive care population and excluded ESRD patients. Following the patient's hospitalization, lower hemoglobin values may persist for 6 months, despite increased ESA dosing. Variability exists in frequency of hemoglobin monitoring and ESA dose changes. To date, no clinical trials have evaluated different approaches to anemia management in hospitalized patients with ESRD, and there are no published guidelines in this area. Based on published observations and clinical experience, we offer recommendations for anemia management around the time of hospitalization in an attempt to define a more rational approach to ESA therapy in this population.

CONCLUSIONS: Trials are needed to define optimal ESA dosing strategies and hemoglobin targets in hospitalized patients with ESRD.

Key Words: anemia, end-stage renal disease, erythropoiesis-stimulating agents

Published Online, January 13, 2009. www.theannals.com, DOI 10.1345/aph.1L195