Renal anemia refractory to erythropoietin

Abstract EN

Background Anemia is a common feature of chronic kidney disease and is associated with poor outcomes.

Renal anemia has a multifactorial etiology, and the major cause is decreased production of erythropoietin (EPO).

The standard of care for the treatment of the renal anemia is EPO for achieving target of hemoglobin levels (11gm /dl), but some causes lead to inadequate response to EPO.

Aim The study aimed to determine the frequency and various factors contributing to the etiology of renal anemia refractory to EPO in patients with end-stage renal disease (ESRD) on hemodialysis (HD).

Patients and methods A descriptive longitudinal study was performed.

The study was carried out on 30 patients with ESRD on HD selected randomly and received EPO drug at the Nephrology Unit and Outpatient Clinic at the Department of Internal Medicine of Assiut University Hospital.

The data were obtained from full medical history and clinical examination, such as general data concerning patients (age, sex, comorbidities, and used medications), which were recorded directly from the patients or from their hospital files, laboratory investigations, and follow‑up of patients for 4 months, with complete blood count examination every month.

Results The study found that of 30 studied patients, 23 (76.7%) had partial response to reach the targeted hemoglobin level and seven (23.3%) had complete response to reach the targeted hemoglobin level of 11 g/dl.

The 23 patients who had partial response had poor nutrition, iron‑deficiency anemia (IDA), inadequate dialysis, arteriovenous fistula and chest infections, drugs containing aluminum, acute blood loss, hypocalcemia, hyperphosphatemia, and hyperparathyroidism.

These may be possible risk factors of renal anemia refractory to EPO.

Conclusions Anemia is a common complication of uremia and a major contributor to morbidity and mortality in HD patients.

The availability of recombinant human EPO has led to almost complete disappearance of severe anemia in HD patients; however, despite an increase in its use and average dose, a substantial percentage of patients still fail to achieve the Hb targets recommended by the international guidelines.

Anemia refractory to EPO is common in HD patients (76.6%), which may be owing to several factors such as bad nutrition, IDA, inadequate dialysis, arteriovenous fistula and chest infection, aluminum‑containing drugs, hypocalcemia, hyperphosphatemia, and hyperparathyroidism.

Recommendations The study recommends to monitor serum levels of iron, calcium, phosphate, and parathyroid hormone at the start, with follow-up by complete blood count monthly, as well as treatment of the possible causes, that is, iron for IDA, antibiotic for infections, calcium therapy for hypocalcemia, and management of hyperphosphatemia and secondary hyperparathyroidism, during treatment of renal anemia by erythropoietin (EPO) drug to responded to it.

Moreover, the study recommends performing more studies on a larger number of patients with ESRD having renal anemia for more demonstration of the possible causes of this condition.