Earlier treatment of anemia with an erythropoiesis-stimulating agent (ESA) may be more effective at decreasing the risk of renal events in patients with chronic kidney disease (CKD) not yet on dialysis, according to investigators.

In a prospective observational study, Tadao Akizawa, MD, of Showa University School of Medicine in Tokyo, and colleagues found that non-dialysis CKD patients may have better renal outcomes if ESA treatment is started when hemoglobin (Hb) levels decrease below 11 g/dL but not less than 10 g/dL.

Dr. Akizawa and colleagues noted that the 2012 guidelines from the Kidney Disease: Improving Global Outcomes initiative states that introduction of ESA therapy should be considered when Hb levels drop below 10 g/dL in non-dialysis CKD patients, but provide no evidence to support this recommendation.

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“Although early detection and management of anemia is considered to be vital,” the authors wrote, “the best time for starting ESA therapy is still uncertain, and it is now imperative that we collect data on the appropriate Hb level for starting ESA therapy.”

The study included 1,113 non-dialysis CKD patients with anemia treated with epoetin beta. The investigators divided subjects into 3 groups based on Hb levels at initiation of therapy: Group I, 10 g/dL or more but less than 11 g/dL; group II, 9 g/dL or more but less than 10 g/dL; and group III, less than 9 g/dL. The primary endpoint was time to first occurrence of any renal event (initiation of renal replacement therapy, doubling of serum creatinine level, or a measurement of estimated glomerular filtration rate (eGFR) less than 6.0 mL/min/1.73 m2).

Renal events occurred in 32.4%, 45.1%, 60.6% of patients in group I, II, and III, respectively, the researchers reported online in Clinical and Experimental Nephrology. Compared with patients in group I, those in group III had a significant 2.5 times increased risk of renal events. Patients in group II had a 48% increased risk, but this was not significant.

“Initiation of ESA therapy when Hb levels decreased below 11 g/dL but not below 10 g/dL could be more effective at reducing the risk of renal events in non-dialysis CKD patients with anemia compared with initiation of ESA therapy at below 9 g/dL or even 10 g/dL,” the researchers concluded.