Adjunctive therapy in anaemia management.

Iron supplementation is essential for adequate response to recombinant human erythropoietin (rHuEPO) or darbepoetin alfa. Oral iron therapy is often ineffective as the quantity of iron absorbed after oral intake may be insufficient to keep pace with the demands of rHuEPO-stimulated erythropoiesis in patients with end-stage renal disease (ESRD). Currently available i.v. iron preparations include dextran, iron gluconate, and iron sucrose. As rare, but serious, adverse reactions to i.v. iron dextran have been reported, alternative preparations may be preferred. Careful monitoring of iron parameters is required to avoid the effects of over-treatment. Renal anaemia and iron therapy are associated with oxidative stress, leading to a shortening of the lifespan of red blood cells (RBC) and resistance to rHuEPO. rHuEPO therapy may also enhance oxidative stress on RBC. Oxidative stress can be attenuated or prevented by supplementation with vitamin E or melatonin. Vitamin E therapy has also been shown to have a rHuEPO-sparing effect. Disturbances of carnitine metabolism may contribute to the development of renal anaemia in ESRD patients. Oral or i.v. L-carnitine therapy results in an increase in haematocrit and a significant decrease in rHuEPO requirement in HD patients. As yet, there is no general recommendation for L-carnitine supplementation for ESRD patients with renal anaemia.