Frequency of ESA Dose Adjustment: A Novel, Independent Predictor of Survival in HD Patients

Background: While hazards linked to high dosages of Erythropoietin Stimulating Agents (ESA) are extensively studied, the potential harm of ESA prescription modality is uncertain. Methods: Dosing patterns of ESA and anemia related parameters were collected monthly during 2008 calendar year and all-cause mortality was assessed in the following year in prevalent in-centre Hemodialysis (HD) patients from 7 Nephrology Units in Tuscany, Italy. Results: During the observation year, monthly Hemoglobin (Hb) levels and weekly ESA dose were 11.40±0.70 gr/dl and 8425±5128 IU, respectively, in the 366 subjects recruited. The higher the ESA dose the lower the Hb values (r - .38, p <0.0001). During the 1-year follow-up 13% of patients died. In comparison with those who eventually died, survivors had significantly higher ESA changes (p .03) and comparable Hb values and ESA dosages. According to Kaplan- Meier subjects with 6 or more ESA changes had significantly better survival (Log Rank 4.94, p .025) than those with less than 6 ESA changes. In a Cox model adjusted for demography, number of co-morbidities and biochemistry covariates, frequency of ESA dose change was highly and independently associated with better survival [HR for mortality 0,79 (95% CI 0,67 - 0,94), p .01]. Conclusion: Frequency of ESA dose changes is a novel independent predictor of survival among HD patients.