Anemia treatment patterns among patients with chronic kidney disease (CKD) in Sweden confirm erythropoietin resistance, inflammation, and an elevated risk for major adverse cardiovascular events (MACE) in a subset of this population, according to investigators.

Of 11,370 nondialysis and 3045 dialysis patients with an estimated glomerular filtration rate (eGFR) of less than 45 mL/min/1.73m2 in the 2015 Swedish national renal registry, 60% and 93%, respectively, had anemia. More patients on dialysis than those not on dialysis received erythropoiesis-stimulating agents (ESAs; 82% vs 24%) and iron (62% vs 21%), Marie Evans, MD, PhD, of Karolinska Institutet in Stockholm, and colleagues reported in the Clinical Kidney Journal. ESA doses were low to moderate: a median 48.2 IU/kg/wk in nondialysis patients and 78.6 IU/kg/wk in dialysis patients. Among ESA-treated patients, 6% to 21% had above-target hemoglobin (Hb) levels of more than 13 g/dL and another 2% to 6% had below-target Hb of less than 9 g/dL.

Inflammation, defined as C-reactive protein levels greater than 5 mg/L, was present in 43% of nondialysis and 50% of dialysis patients treated with ESAs, and correlated with the erythropoietin resistance index (ERI) and higher ESA doses. A high ERI value of 0.88 (IU/wk)/kg/(g/dL), in turn, associated with a 45% and 66% increased risk of MACE in nondialysis and dialysis patients, respectively, compared with an ERI value of less than 0.44 (IU/week)/kg/(g/dL).

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Likewise, ESA doses exceeding 88 IU/kg/week correlated with 36% and 60% increased risks for MACE, respectively, compared with ESA doses lower than 44 IU/kg/week. Use of intravenous iron associated with neither inflammation nor MACE.

“The management of anaemia in the CKD population remains challenging and, given the proportion of ESA-treated patients with Hb>12 g/dL, maintaining Hb levels within the recommended target appears difficult,” Dr Evans’ team commented. “Iron use may be suboptimal in this population, especially in [nondialysis] CKD.”

Disclosure: This clinical trial was supported by Astellas Pharma. Please see the original reference for a full list of authors’ disclosures.

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Evans M, Bower H, Cockburn E, et al. Contemporary management of anaemia, erythropoietin resistance and cardiovascular risk in patients with advanced chronic kidney disease: a nationwide analysis. Clin Kid J. doi: 10.1093/ckj/sfaa054