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Treatment Of Anaemia In Chronic Kidney Disease

Erythropoiesis-stimulating agents (ESA) therapy

ESAs are a group of medications which are used to stimulate the bone marrow to produce red blood cells. These agents are used to correct anemia in patients with chronic kidney disease.

What are the types of ESAs available currently in Malaysia?

Currently, there are five types of ESAs available in Malaysia. They are :

  • Erythropoietin alfa – @Eprex and Binocrit
  • Erythropoietin beta – @Recormon
  • Methoxy polyethylene glycol-epoetin beta – @Mircera
  • Darbepoetin alfa – @Aranesp

How to administer ESAs?

ESAs are administered as injections under the skin (subcutaneous) or directly into the veins (intravenous). The intravenous route would be more suitable for patients on haemodialysis as it can be given via a dialysis fistula or via a temporary haemodialysis catheter during the haemodialysis treatment. However, in patients with Stage 3-5 CKD or on peritoneal dialysis, administration of ESAs via the subcutaneous route is more feasible that the intravenous route.

It is important to note that ESAs differ in their route of administration. Please consult your doctor.

ESAs are divided into short-acting agents and longer-acting ones. Those which are short-acting will need to be administered more frequently compared to those that longer-acting.

When to start ESAs?

  • When haemoglobin levels < 10 gm/dl or haematocrit (HCT) <30%
  • When the patient is symptomatic especially in the elderly or those with heart disease

Note : Prior to commencing ESAs it is important that the patient has adequate blood pressure control (see side-effects below) and has good iron stores as Iron is a basic requirement for formation of new red blood cells .

What are the side-effects of ESAs?

  • High blood pressure
  • Hypertensive encephalopathy with fits
  • Vascular access thrombosis

When to stop ESAs?

Most patients will require ESA treatment for life to sustain target haemoglobin levels in CKD. The target haemoglobin level that is recommended currently is between 10-11.5 gm/dl. Blood tests to monitor hemoglobin levels will be required for a minimum of once every three months, but more frequent when ESAs therapy began or when doses are changed. Dose adjustments are required to maintain levels within the target range. Higher haemoglobin levels do not confer any additional benefit and may even increase cardiovascular morbidity and death.

A small number of patients are eventually able to achieve target levels without ESAs after many years on dialysis.

Examples of the ESAs in Malaysia

1

2

Erythropoietin alfa

3

4

Erythropoietin beta

5

Darbepoeitin alfa

Last Reviewed : 3 May 2016
Writer : Dr. Anita Bhajan Manocha
Accreditor : Dr. Sunita Bavanandan

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