NDT Advance Access originally published online on January 12, 2007
Nephrology Dialysis Transplantation 2007 22(3):963; doi:10.1093/ndt/gfm009
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Reply
Email: abraham.jacob{at}rwh-tr.nhs.ukSir,
We thank Dr Shaldon for his comments, but find it slightly disappointing that he focuses on minutiae and semantics that are not related to the main focus of our study. We agree that some of the issues raised in the introductory paragraph regarding management of anaemia in chronic kidney disease can be debated. These are issues from the published literature and certainly not the ‘claim’ of the authors of this article. The focus of the publication was ‘antibody-mediated pure red cell aplasia’ and was certainly not a discussion on the much wider topic of management of anaemia in dialysis patients [1].
Dr Shaldon's letter refers to publications from the 1960s relating to management of CKD with dialysis and intravenous iron. As evident from the published literature, quality of life (QoL) then was less of an issue in clinical practice, and the tools to measure QoL were even less standardized than they are today. ‘Maintaining patients’ Hb levels between 9–10 g/100 ml on IV iron alone’ has to be assessed against this background. There has always been a view that long dialysis reduces the need for transfusion, and while this is an admirable achievement, this is not something that is appropriate for, or acceptable to, all patients.
Randomized controlled multicentre trials since the advent of EPO have confirmed the improvement in QoL with this agent in dialysis patients, and have also indicated that this is not maximized at a Hb of 9–10 g/100 ml [2–4]. It is widely accepted that administration of intravenous iron leads to improvements in haematocrit levels in haemodialysis patients and enhances Hb responsiveness when used in conjunction with epoetin [5]. Our use of EPO is consistent with recognized standards and practice elsewhere.
Although there are several survival studies suggesting no benefit in normalizing Hb in chronic kidney disease patients, no study has ever been conducted in a large-enough sample size to investigate whether EPO therapy increases survival compared with standard practice in the pre-EPO era using regular blood transfusions and/or IV iron, but it would take a very brave nephrologist to suggest that the minimization of blood transfusions and avoidance of iron overload by EPO has not impacted on survival.
The declared conflict of interest relates only to one of the authors, whose involvement was only in the investigation of pure red cell aplasia and not in the direct clinical care of the patient. Even this author has espoused the benefit of IV iron with EPO, a practice which has been shown to decrease the use of EPO [5]. Volume discounting is widely used in all ‘markets’, including health care, and made use of by both the buyers and the sellers.
Conflict of interest statement. None declared.
Department of Haematology
New Cross Hospital
Wolverhampton, West Midlands
WV10 0QP
UK
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] - Lillevang ST and Pedersen FB. (1990) Quality of life of hemodialysis patients before and after erythropoietin therapy. A double-blind, randomized, placebo controlled study. Ugeskr Laeger 152:2999–3002.[Medline]
- . Canadian Erythropoietin Study Group. (1990) Association between recombinant human erythropoietin and quality of life and exercise capacity of patients receiving haemodialysis. Br Med J 300:573–578.
[Abstract/Free Full Text] - Evans RW, Rader B, Manninen DL. (1990) The quality of life of hemodialysis recipients treated with recombinant human erythropoietin. Cooperative Multicenter EPO Clinical Trial Group. JAMA 263:825–830.
[Abstract/Free Full Text] - Macdougall IC, Tucker B, Thompson J, Tomson CR, Baker LR, Raine AE. (1996) A randomized controlled study of iron supplementation in patients treated with erythropoietin. Kidney Int 50:1694–1699.[Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  E. D. Pagourelias, C. Koumaras, A. I. Kakafika, K. Tziomalos, P. G. Zorou, V. G. Athyros, and A. Karagiannis Cardiorenal Anemia Syndrome: Do Erythropoietin and Iron Therapy Have a Place in the Treatment of Heart Failure? Angiology, February 1, 2009; 60(1): 74 - 81. [Abstract] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||