What is new in anemia treatment in CKD since 2010?

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What is new in anemia treatment

in CKD since 2010?

Pr. J-M Krzesinski CHU Liège

5th_{Belgian Dialysis Symposium}

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Role of iron deficiency, Inflammation, obesity and DN

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What is the dilemma for Hb correction?

HRQOL CV Risk (?)

High Hb target (>12 g/dl)

with ESA

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stroke

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DOPPS Male AVF Cystic disease Smoking Lung disease

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Retrospective 95000 pts

HD Japan

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Worse effect of ESA high dosage and ESA hyporesponsiveness

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Testosterone deficiency

NDT 2011 Carrero et al : hypogonadism as a cause of anemia and ESA resistance in men with CKD

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1g IV Fer 2X500 vs IS 10X100 mg Superparamagnetic

iron oxide coated with CH shell

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60000 u IV EPO alpha

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Single high dose Epoietin bêta after reperfusion in

STEMI (Prunier et al Am H J 2012) (EPOMI study)

• 110 patients

• 1000 u/Kg IV EPOETIN beta immediately after

reperfusion

• Cardiac magnetic resonance

• Transient favorable effects on LV volume (at 5d)

• No reduction in infact size at 3 months

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EPO: Good or Bad for Cancer?

• EPO binds its receptor EPO R

surface of RBC progenitors

in the bone marrow.

• EPO binds EPO R expressed

on the surface of cancer cells

and may elicit tumor growth

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Moreover, increase risk of

venous thromboembolism

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ESA and cancer risk?

• 2009: (Cochrane database syst rev) ESA treatment in cancer

patients increased on study mortality and worsened overall survival.

• This was less pronounced for patients undergoing chemotherapy. • There is also a risk for venous thromboembolic events,

particularly when ESA are used off label.

• 2012: (Br J Cancer) ESAs may have little effect on disease

progression in chemotherapy patients. Preclinical data indicate an effect of ESAs on tumour growth is not strongly supported.

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just

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just End March 2012

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Transfusion, CV events, mortality

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HIF stabilizers

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So, in CKD, there is a problem of abnormal oxygen sensing

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Conclusions

• Partial correction (Hb in the range of 10-11.5 g/dL) of

CKD-related anemia appears a safer strategy during the

last 5y. So recommendation is to start ESA only when

Hb <10 and to avoid too high ESA dose (CE DOSE

study ongoing in HD)!

• Identify resistant patients and try to improve it.

• Importance of adequate iron management and of

hepcidin role in the all-mortality risk in CKD.

• Newer strategies for correcting anemia are currently

explored.

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