Division of Nephrology, Department of Medicine, Indiana University School of Medicine, and Roudebush VA Medical Center, 1481 West 10th Street, 111N, Indianapolis, IN 46202, USA.
Clin J Am Soc Nephrol. 2010 Jul;5(7):1340-6. doi: 10.2215/CJN.02830310. Epub 2010 May 6.
Among patients with chronic kidney disease (CKD), erythropoiesis-stimulating agents (ESAs) are approved for avoiding transfusions, a risk that increases when hemoglobin (Hgb) falls to <10 g/dl. Transfusions increase sensitization, prolong the waiting time to and the likelihood of transplantation, and when transplantation is performed worsen graft survival. Accordingly, the risk of transfusion among those expecting transplantation is comparable to that of cardiovascular events. Nonetheless, targeting Hgb to >13 g/dl is associated with increased cardiovascular events. Paradoxically, if this level is achieved mortality is lower. The anemia paradox--higher cardiovascular events when targeting higher Hgb but lower events when patients achieve these targets--appears to be at least partially attributable to a hyporesponse to ESAs. Whether it is the ESAs or conditions that lead to the increased ESA dose that provokes morbidity cannot be answered definitively at present. The lowest ESA dose to achieve the desired level of anemia correction appears to be a safer strategy. In acute illnesses, reducing the dose of ESAs or stopping it altogether may aggravate anemia, but this may be permissible. The rate of rise in Hgb>1 g/dl in any 2-week period is associated with an increase in blood pressure (BP) and poor outcomes. Accordingly, while initiating and maintaining ESA therapy, monitoring BP at home twice daily is warranted. The clinical decision-making process in managing anemia should consider the risks of transfusion; kidney transplant potential; presence of cancer; and the risks of stroke, heart failure, and possibly death. Above all, clinical decision-making should incorporate patient preference.
在慢性肾脏病（CKD）患者中，促红细胞生成素刺激剂（ESA）被批准用于避免输血，当血红蛋白（Hgb）降至<10 g/dl 时，这种风险会增加。输血会增加致敏作用，延长等待时间和移植的可能性，并且在进行移植时会降低移植物的存活率。因此，即将进行移植的患者的输血风险与心血管事件的风险相当。尽管如此，将 Hgb 目标值设定为>13 g/dl 与增加心血管事件相关。具有讽刺意味的是，如果达到这个水平，死亡率反而会降低。贫血悖论——将 Hgb 目标值设定得越高，心血管事件的发生率就越高，但当患者达到这些目标时，事件发生率就越低——似乎至少部分归因于对 ESA 的低反应。目前还不能明确确定，导致更高 Hgb 目标值的心血管事件增加但患者达到这些目标时事件减少的原因是 ESA 还是导致 ESA 剂量增加的情况。达到所需贫血纠正水平的最低 ESA 剂量似乎是一种更安全的策略。在急性疾病中，减少 ESA 的剂量或完全停止使用可能会加重贫血，但这可能是允许的。在任何 2 周内 Hgb 升高>1 g/dl 的速度与血压（BP）升高和不良预后相关。因此，在开始和维持 ESA 治疗时，有必要在家中每天两次监测 BP。管理贫血的临床决策过程应考虑输血的风险；肾移植的潜力；癌症的存在；以及中风、心力衰竭和可能死亡的风险。最重要的是，临床决策应纳入患者的偏好。
