Resistance to erythropoiesis stimulating agents (ESA) predicts poor survival in hemodialysis patients, according to a new study presented at the European Renal Association-European Dialysis and Transplant Association 53rd Congress in Vienna.

Zijin Chen, MD, and Xianong Chen, MD, of Ruijin Hospital, Shanghai Jiaotong University in China, examined both all-cause and cardiovascular (CVD) mortality among 250 maintenance hemodialysis patients treated at their hospital in 2011. The median age was 57, and 62% of patients were men. The median dialysis vintage was 2 years. ESA dose was recorded during the 1-year observation period. The investigators also calculated an erythropoietin resistance index (ERI) for each patient by dividing the weekly weight-adjusted dose of ESA by the hemoglobin level.

Results showed that certain risk factors were significantly associated with higher weekly ESA dose, including female gender, using intravenous iron, having longer dialysis duration, and displaying lower levels of hemoglobin, pre-albumin, and single pool Kt/V.

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Similar results were obtained for higher ERI. Correlating factors included female gender, longer dialysis vintage, and lower BMI. Other factors included higher alkaline phosphatase and C-reactive protein levels and lower levels of hemoglobin, total iron-binding capacity, and single pool Kt/V.


Over 3 years of follow-up, 26.4% of patients died. A Kaplan-Meier analysis revealed that patients with a high weekly dose of ESA had the highest all-cause mortality. Patients with higher ERI also had a greater risk for death from any cause.


Having a high weekly ESA dose was associated with more than twice the risk for all-cause mortality compared with a low ESA dose, after adjustments for age and gender. Likewise, high ERI was associated with triple the risk. The latter held after multivariate analyses. Older age, higher pre-dialysis systolic blood pressure, lower albumin level, lower urea reduction ratio, and lower blood flow were identified as risk factors.


The researchers observed no significant differences in risk for CVD mortality. They found that older age, higher pre-dialysis systolic blood pressure, and lower mean corpuscular hemoglobin were risk factors.

“In clinical practice, we can calculate ERI index to assess clinical status or to evaluate prognosis of MHD patients,” the investigators stated.


1. Chen Z and Chen X. SP549. Erythropoietin Stimulating Agents  Resistance is Associated With All-Cause Mortality in Maintenance Hemodialysis Patients. Nephrol Dial Transplant (2016) 31 (suppl 1): i274-i275. doi: 10.1093/ndt/gfw174.04.