Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.
Centre for Inflammatory Disease, Department of Medicine, Imperial College London, London, UK.
Hemodial Int. 2022 Oct;26(4):519-526. doi: 10.1111/hdi.13030. Epub 2022 Jul 14.
Anemia protocols for hemodialysis patients usually titrate erythropoietin (ESA) according to hemoglobin and iron according to a threshold of ferritin, with variable response seen. A universally optimum threshold for ferritin may be incorrect, and another view is that ESA and iron are alternative anemia treatments, which should be selected based on the likely response to each. Hemodialysis patients developing moderate anemia were randomised to treatment with either an increase in ESA or a course of intravenous iron. Over 2423 patient-months in 197 patients, there were 133 anemia episodes with randomized treatment. Treatment failure was seen in 20/66 patients treated with ESA and 20/67 patients treated with iron (30.3 vs. 29.9%, p = 1.0). Successful ESA treatment was associated with lower C-reactive protein (13.5 vs. 28.6 mg/L, p = 0.038) and lower previous ESA dose (6621 vs. 9273 μg/week, p = 0.097). Successful iron treatment was associated with lower reticulocyte hemoglobin (33.8 vs. 35.5 pg, p = 0.047), lower hepcidin (91.4 vs. 131.0 μg/ml, p = 0.021), and higher C-reactive protein (29.5 vs. 12.6 mg/L, p = 0.085). A four-variable iron preference score was developed to indicate the more favorable treatment, which in a retrospective analysis reduced treatment failure to 17%. Increased ESA and iron are equally effective, though treatment failure occurs in almost 30%. Baseline variables including hepcidin can predict treatment response, and a four-variable score shows promise in allowing directed treatment with improved response rates.
血液透析患者的贫血方案通常根据血红蛋白和铁来调整促红细胞生成素（ESA）的剂量，根据转铁蛋白饱和度（TSAT）设定补铁的阈值，但疗效存在差异。一个普遍适用的铁蛋白阈值可能并不准确，另一种观点认为 ESA 和铁剂是贫血的两种替代治疗方法，应根据每种治疗方法的疗效来选择。将出现中度贫血的血液透析患者随机分为 ESA 剂量增加组或静脉铁剂治疗组。在 197 名患者的 2423 个患者月中，共有 133 例贫血发作接受了随机治疗。ESA 治疗组有 20/66 例（30.3%）和铁剂治疗组有 20/67 例（29.9%）治疗失败（p=1.0）。ESA 治疗成功与较低的 C 反应蛋白（13.5 比 28.6mg/L，p=0.038）和较低的ESA 剂量（6621 比 9273μg/周，p=0.097）相关。铁剂治疗成功与较低的网织红细胞血红蛋白（33.8 比 35.5pg，p=0.047）、较低的铁调素（91.4 比 131.0μg/ml，p=0.021）和较高的 C 反应蛋白（29.5 比 12.6mg/L，p=0.085）相关。开发了一个四变量的铁剂偏好评分来指示更有利的治疗方法，在回顾性分析中，该评分将治疗失败率降低到 17%。增加 ESA 和铁剂的疗效相当，但仍有近 30%的患者治疗失败。包括铁调素在内的基线变量可以预测治疗反应，一个四变量评分显示有希望通过提高反应率来指导治疗。
