Renal Anemia: Conflicts and Controversies

149 Pages·2002·3.46 MB·English

by  Eli A. Friedman (auth.)

Renal Anemia
Conflicts and Controversies
Renal Anemia
Conflicts and Controversies
Edited by
Onyekachi Ifudu
Associate Professor of Medicine
Director. Inpatient Dialysis Services
SUNY Downstate Medical Center. Brooklyn. New York
Springer-Science+Business Media, B.Y.
Library of Congress Cataloging-in-Publication Data is available.
Printed Dill/dei-IreI' paper
ISBN 978-90-481-6045-7 ISBN 978-94-015-9998-6 (eBook)
DOI 10.1007/978-94-015-9998-6
All Rights Reserved
(. 2002 Springer Science+Business Media Dordrecht
Originally published by Kluwer Academic Publishers in 2002.
Softcover reprint of the hardcover 1st edition 2002
No part of this publication may be reproduced or
utilized in any form or by any means. electronic. mechanical.
including photocopying. recording or by any information storage and
retrieval system, without written permission from the copyright owner.
Dedication
To Munachiso "my moon", and Audrey for bringing such joy.
Table of Contents
Dedication v
Introduction to the Conference
Eli A. Friedman IX
Conference Participants Xl
1. Correcting anemia slows renal disease progression
Eli A. Friedman
2. Does treatment with EPO improve RBC survival?
Clinton D. Brown, Zhong H. Zhao, Lorraine L. Thomas,
Robert deGroof and Eli A. Friedman 9
3. Has the best route of administration for epoetin
been established?
Anatole Besarab and Rebecca J. Schmidt 15
4. Is renal anemia management determined by science
or reimbursement regulations?
Chaim Chary tan 29
5. When does anemia impact the heart in chronic
kidney disease?
Adeera Levin 37
6. Improvements in anemia management with darbepoetin
alfa, a new erythropoiesis stimulating protein
Jill S. Lindberg 49
7. Normalizing hematocrit in renal failure: dangerous or
desirable?
lain C. Macdougall 65
8. Do race, gender or mode of dialysis modulate
erythropoietin response?
Barbara G. Delano 81
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viii Table of Contents
9. Are uremic inhibitors of erythropoiesis clinically relevant?
Onyekachi Ifudu 89
10. Do ACE inhibitors limit response to EPO and should
EPO be continued in patients with sepsis or fever?
Mora O. Salifu 99
11. Is secondary hyperparathyroidism a significant cause
of renal anemia?
Onyekachi Ifudu 107
12. Is long-term intravenous iron therapy risky?
Wendy 1. St. Peter 115
13. Anemia and erythropoietin therapy in kidney transplant
recipients: where are the data?
Onyekachi Ifudu 123
14. Intravenous iron treatment: a comparison of available
drugs
Steven Fishbane 129
Epilogue
Eli A. Friedman 139
Index 141
Introduction to the Conference
Eli A. Friedman
Nephrology evolved as a discipline of value to sick people as the
consequence of sometimes startling unexpected vanguard advances that
transformed the kidney doctor from a sideline observer to an active
interventionist. As a prime example of the transformation in practice that
might derive from a single experiment reflect on Willem J. Kolff's 1943
invention of a practical artificial kidney using sausage casing and
cellophane. At once, uremia was in acute renal failure was converted from
a frustratingly inexorable march culminating in death to a signal for
repetitive treatment.
Similarly, less than a generation later, Belding H. Scribner devised a
regimen for repetitive access to arterial and venous blood thereby
permitting maintenance hemodialysis, a therapy that sustains more than
half-a-million individuals who would otherwise have died from so called
end-stage renal disease (ESRD). Contemporaneous with construction of
hemodialysis protocols for ESRD. successful kidney transplantation and
peritoneal dialysis were introduced affording a menu of choices for
formerly hopeless ESRD patients.
Once life despite ESRD was proven extendable - a miraculous accom
plishment vividly recalled by those old enough to have experienced the
therapeutic triumph impact on their patients - attention shifted to the
quality and complexity of dialysis-salvaged lives. Recognition of the
adverse impact of hypertension within the first years of applying main
tenance hemodialysis was followed by appreciation of the danger imposed
by hyperphosphatemia and aluminum contaminated dialysate.(and later
phosphate binders). By the end of a decade of maintenance hemodialysis,
antihypertensive medications along with unpalatable phosphate binders
became bedrock accompaniments of dialysis treatment. Two pervasive
problems limited rehabilitation in maintenance hemodialysis as the 1980s
began: delivery of insufficient dialysis and anemia.
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x Introduction to the Conference
Clear correlation between the length of dialysis treatments and survival
as well as comparisons between "good" and "bad" dialysis facilities led to
standards in the form of "quality assurance" with a targeted minimum of
four hours of hemodialysis per treatment. Improvement in anemia eluded
nephrologists who tried and discontinued periodic transfusions of eyrtho
cytes. androgens and cobalt. And then. the astonishing and profound
effect of injected erythropoietin eliminated severe anemia in the absence of
infections. active bleeding. extrarenal diseases. and primary hematologic
disorders. By the end of the 20th Century. erythropoietin was a fixed
element of dialytic therapy for about 90% of American dialysis patients at
an annual cost in excess of $ 3 billion.
Still. something was not right about our use of erythropoietin. Dose
response curves were highly variable and the perceived need for and
response to supplemental iron was inconstant and unpredictable. Two
competing explanations were considered: 1) Many dialysis patients are
iron deficient though treated with oral iron supplements. affording strong
evidence for the hypothesis that dialysis patients must receive iron
parenterally changing usual practice. 2) Insufficient dialysis blunts
erythropoietin efficacy and may be masked by some response in terms of
hemoglobin/hematocrit rise when iron is administered. These Conference
Proceedings address implementation of the wondrous benefits that can be
bestowed by erythropoietin usage. Considering the expense and incon
venience imposed on patients by an established program of erythropoietin
treatment, it is appropriate that all those who prescribe the hormone
optimize its application and benefits. The pages that follow represent the
efforts of accomplished workers who strive to attain this objective.
Conference Participants: Brooklyn, New York,
USA, September 21,2001
Program Director Wendy L. st. Peter, Pharm.D, F.C.C.P,
Onyekachi Ifudu, M.D., M.Sc B.C.P.S.
Associate Professor of Medicine Associate Professor
Director. Inpatient Dialysis Services College of Pharmacy. University of
SUNY Downstate Medical Center Minnesota
Brooklyn. New York Co-investigator. Nephrology Analytical
Services
Guest Faculty Hennepin County Medical Center.
Minneapolis
Adeera Levin, M.D.
Associate Professor of Medicine Rebecca J. Schmidt, D.O., F.A.C.P.
Program Director. Nephrology Associate Professor of Medicine
St. Paul's Hospital. Vancouver. Canada West Virginia University School of Medi
President. Canadian Society of cine
Nephrology
SUNY Downstate Medical Center FacuIty
Chaim Chary tan. M.D.
Chief. Renal Division
Clinton Brown, M.D.
NY Hospital Medical Center of Queens
Assistant Professor of Medicine
Clinical Professor of Medicine
Director. Ambulatory Dialysis Center
Cornell University College of Medicine
& Hyperlipidemia Clinic
Steven Fishbane, M.D.
Associate Professor of Medicine Barbara Delano, M.D., M.P.H.
SUNY Stony Brook Professor of Medicnine
Associate Chief of Nephrology Director. Home Hemodialysis & CAPO
Winthrop-University Hospital. Mineola
Eli A. Friedman, M.D., M.A.C.P
Jill Lindberg, M.D. Distinguished Teaching Professor of Med
Director of Nephrology Research icine
Director of Metabolic and Bone Clinics Chief. Renal Disease Division
Associate Section Head - Hemodialysis
Ochsner Foundation Hospital. Mariana Markell, M.D.
New Orleans Associate Professor of Medicine
Director. Transplant Nephrology
lain C. Macdougall, BSc, M.D., F.R.C.P.
Consultant Nephrologist
Moro Salifu, M.D.
King's College Hospital. London
Assistant Professor of Medicine
Renal Disease Division
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