Current guidelines have not fully addressed the use of erythropoiesis-stimulating agents (ESAs) in patients with both chronic kidney disease (CKD) and cancer. The Kidney Disease Improving Global Outcomes (KDIGO) 2012 anemia guideline suggested using ESAs “with caution” in patients with CKD accompanied by active malignancy or a history of malignancy. In a recent issue of the American Journal of Kidney Diseases, Sumeska Thavarajah, MD, of Johns Hopkins University in Baltimore, and Michael J. Choi, MD, of MedStar Georgetown University Hospital in Washington, DC, discussed a prudent clinical approach to using ESAs in patients with CKD and cancer.

In CKD patients, anemia due to cancer care (ie, chemotherapy, radiation therapy, inflammation, and frequent venipuncture) compounds erythropoietin deficiency, iron deficiency, and inflammation of CKD. The reviewers encouraged careful screening of such patients for blood loss, hemolysis, or vitamin/nutritional deficiencies, as well as administration of intravenous iron before consideration of ESA therapy.

According to the KDIGO 2012 guideline, ESA is not needed for patients with hemoglobin (Hb) levels exceeding 10 g/dL. Only patients with Hb less than 10 g/dL warrant ESA to bring or keep values to above 9 g/dL.

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Several studies hint at potential complications of ESAs, including increased risk for cancer progression, thrombosis, worsening hypertension, and stroke.

“Careful assessment of malignancy-associated thrombotic risk before ESA treatment initiation and monitoring of thromboembolic complications after its administration is of paramount importance,” Drs Thavarajah and Choi concluded.

Given the uncertainties, ESA therapy may be administered up to an Hb target of 10 g/dL, the lower target range of anemia in CKD, according to the authors. For patients with cancer and CKD either receiving or not receiving dialysis, a “reasonable approach” may be to administer the lowest ESA dose possible to minimize symptoms without exceeding the Hb target of 10 g/dL.

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Thavarajah S, Choi MJ. The use of erythropoiesis-stimulating agents in patients with CKD: A clinical approach [published online August 5, 2019]. Am J Kidney Dis. doi: 10.1053/j.ajkd.2019.04.022