Hörl W H
Department of Nephrology, University of Vienna, Austria.
Nephrol Dial Transplant. 1999;14 Suppl 2:50-60. doi: 10.1093/ndt/14.suppl_2.50.
Adjuvant therapy may allow patients being treated with epoetin to derive greater clinical benefits. Iron supplementation is currently the most widely used form of adjuvant therapy; intravenous (i.v.) iron is required by the majority of haemodialysis patients receiving epoetin. Measurement of hypochromic red blood cells is the most direct way of assessing iron supply to the bone marrow. During the correction phase, a dose of i.v. iron equivalent to 50 mg/day is recommended, with the total dose not exceeding 3 g. When subclinical vitamin C deficiency is suspected, ascorbic acid may be given orally (1-1.5 g/week) or i.v. (300 mg three times weekly at the end of dialysis). The active vitamin D metabolites alfacalcidol and calcitriol may, under some circumstances, improve anaemia and reduce epoetin dosage requirements. Vitamin B6 requirements are increased during epoetin therapy, and supplementation at a dose of 100-150 mg/week is recommended. Supplementation of vitamin B12 is optional. Folic acid is supplemented routinely in haemodialysis patients, though evidence that it increases the efficacy of epoetin is limited. Low doses (2-3 mg/week) should normally be sufficient to maintain optimal folic acid stores in epoetin-treated patients, although higher doses are necessary for patients with hyperhomocysteinaemia. L-Carnitine supplementation may be appropriate in some patients with anaemia of chronic renal failure (CRF) unresponsive to, or requiring large doses of, epoetin. Androgens potentially could reduce epoetin costs in countries with limited resources, but should only be used in men older than 50 years with a remnant kidney. Recent animal studies indicate that the combination of epoetin and insulin-like growth factor 1 might be beneficial in CRF patients. High doses of angiotensin-converting enzyme (ACE) inhibitors should be reserved for dialysis patients who have hypertension that cannot be controlled by other agents, or who require an ACE inhibitor for treatment of heart failure.
辅助治疗可能使接受促红细胞生成素治疗的患者获得更大的临床益处。铁补充剂是目前使用最广泛的辅助治疗形式；大多数接受促红细胞生成素治疗的血液透析患者需要静脉注射铁剂。检测低色素红细胞是评估骨髓铁供应的最直接方法。在纠正阶段，建议静脉注射铁剂的剂量相当于50毫克/天，总剂量不超过3克。当怀疑存在亚临床维生素C缺乏时，可口服抗坏血酸（1 - 1.5克/周）或静脉注射（透析结束时每周三次，每次300毫克）。在某些情况下，活性维生素D代谢产物阿法骨化醇和骨化三醇可能改善贫血并降低促红细胞生成素的剂量需求。促红细胞生成素治疗期间维生素B6的需求量增加，建议补充剂量为100 - 150毫克/周。维生素B12的补充为可选。血液透析患者常规补充叶酸，不过其增加促红细胞生成素疗效的证据有限。低剂量（2 - 3毫克/周）通常足以维持接受促红细胞生成素治疗患者的最佳叶酸储备，尽管高同型半胱氨酸血症患者需要更高剂量。对于一些对促红细胞生成素无反应或需要大剂量促红细胞生成素的慢性肾衰竭（CRF）贫血患者，补充L - 肉碱可能是合适的。在资源有限的国家，雄激素可能会降低促红细胞生成素的成本，但仅应用于年龄超过50岁且有残余肾的男性。最近的动物研究表明，促红细胞生成素和胰岛素样生长因子1联合使用可能对CRF患者有益。高剂量的血管紧张素转换酶（ACE）抑制剂应仅用于高血压无法通过其他药物控制的透析患者，或需要ACE抑制剂治疗心力衰竭的患者。
