NDT Advance Access originally published online on January 12, 2007
Nephrology Dialysis Transplantation 2007 22(3):962; doi:10.1093/ndt/gfl791
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Does erythropoetin improve survival in ESRD haemodialysis patients?
Email: stanley.shaldon{at}libello.comSir,
The introductory claims of Jacob and others [1] regarding the benefits associated with the use of recombinant human erythropoietin in the dialysis patient reflect an unfamiliarity with the ESRD treatment prior to the erythropoietin (EPO) era. The statement that the vast majority of dialysis patients required regular blood transfusions prior to the introduction of EPO is not completely true. Indeed, as early as 1967 we reported 50 patients on maintenance haemodialysis without blood transfusions [2,3] and subsequent to our observations, many centres were able to maintain their patients’ Hb levels between 9–10 g/100 ml on IV iron alone [4,5]. The statement that survival has been improved in the dialysis population by erythropoietin is even more controversial. The references quoted by Jacob refer exclusively to pre-dialysis patient populations and the most recent KDOQI guidelines on the subject [6] confirm earlier suggestions that Hb > 11 g/100 ml was not a valid surrogate for survival [7]. Finally, in a DOPPS comparison of survival and Hb levels, Japan tops the bill with the lowest Hb (10 g/100 ml) [8] and the best survival data [9]. Whilst not wishing to diminish the benefits of erythropoietin therapy in ESRD patients, the principle of volume discounting to the benefit of the prescriber, as practiced in USA [10] should not be ignored in evaluating claims supporting the benefits of EPO therapy, particularly when the authors of such claims often have declared conflicts of interest.
Conflict of interest statement. None declared.
References
- Jacob A, Sandhu S, Nicholas J, et al. (2006) Antibody-mediated pure red cell aplasia in a dialysis patient receiving darbepoetin alfa as the sole erythropoetic agent. Nephrol Dial Transplant 21:2963–2965.
[Free Full Text] - Shaldon S. (1967) Chronic dialysis without transfusion. Lancet 1:783–784.
- Crockett RA, Baillod RA, Hopewell J, Shaldon S. (1967) Maintenance of 50 patients on intermittent haemodialysis without blood transfusion. Proc Eur Dial Transpl Assoc 4:17–23.[Medline]
- Granolleras C, Oulès R, Branger B, et al. (1993) Iron supplementation of hemodialysis patients receiving recombinant human erythropoietin therapy. In Bauer C, Koch KM, Scigalla P, Wieczorek L (Eds.). Erythropietin Molecular Physiology and Clinical Applications(Marcel Dekker, New York) pp. 211–217.
- Granolleras C, Zein A, Oulès R, et al. (1997) Continuous administration of intravenous iron during hemodialysis. Nephrol Dial Transplant 12:1007–1008.
[Abstract/Free Full Text] - KDOQI clinical practice guidelines and clinical practice recommendations for anaemia in chronic kidney disease. Am J Kidney Dis (2006) 47:S11–S145.[CrossRef][Medline]
- Cotter DJ, Stefanik K, Zhang Y, Thamer M, Scharfstein D, Kaufman J. (2004) Hematocrit was not validated as a surrogate end point for survival among epoetin-treated hemodialysis patients. J Clin Epidemiology 57:1086–1095.[CrossRef][ISI][Medline]
- Pisoni RL, Bragg-Gresham JL, Young EW, et al. (2004) Anemia management and outcomes from 12 countries in the dialysis outcomes and practice patterns study (DOPPS). Am J Kidney Dis 44:94–111.[CrossRef][ISI][Medline]
- Held PJ, Brunner F, Odaka M, et al. (1990) Five-year survival for end-stage renal disease patients in the United States, Europe, and Japan, 1982 to 1987. Am J Kidney Dis 15:451–457.[ISI][Medline]
- Cotter DJ, Tharner M, Narasimhan M, Zhang W, Bullock K. (2006) Translating epoetin research into practice: the role of government and the use of scientific evidence. Health Affairs 25:1249–1259.
[Abstract/Free Full Text]
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