We suggest that the initial ESA dose should be determined by the individual’s Hb level, the desired target Hb range, the observed rate of increase in Hb level and clinical circumstances. (2B)
Rationale
For initiation of ESA therapy, several points are to be considered:
- Type(s) of licensed ESAs available
- Initial ESA dose
- ESA dose adjustment: dose required for Hb correction vs. maintenance.
- Route of ESA administration
- Frequency of ESA administration that best fit patient requirements and achieve maximal convenience
- Monitoring for the anticipated response in terms of Hb rise, rate of Hb rise, possible adverse effect (e.g. hypertension).
In general, the aim of initial ESA therapy is to achieve a rate of increase in Hb levels of 10 to 20 g/L per month. This rate of rise is considered safe as evidenced from interventional trials on people who are ESA naïve (1-3). In CKD patients with initial Hb levels less than target range, these trials have shown the mean initial rate of Hb level increase to be in the range of 7 to 25 g/L in the first 4 weeks. This rate of Hb increase is affected by the population, iron status, initial ESA dose, and the frequency and route of ESA administration.
References
- Eschbach JW, Abdulhadi MH, Browne JK, et al. Recombinant human erythropoietin in anaemic patients with end-stage renal disease. Results of a phase III multi-centre clinical trial. Ann Intern Med. 1989 Dec 15;111(12):992-1000.
- Eschbach JW, Kelly MR, Haley NR et al. Treatment of the anaemia of progressive renal failure with recombinant human erythropoietin. N Engl J Med.1989 Jul 20; 321(3):158-63.
- Locatelli F, Olivares J, Walker R, et al; European/ Australian NESP 980202 Study Group. Novel erythropoiesis stimulating protein for treatment of anaemia in chronic renal insufficiency. Kidney Int. 2001 Aug;60(2):741-7.