What is the role of erythropoiesis-stimulating agents (ESAs) in the treatment of anemia of chronic disease and renal failure?

Updated: Apr 13, 2020
  • Author: Gates B Colbert, MD, FASN; Chief Editor: Emmanuel C Besa, MD  more...
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The preferred initial form of therapy for anemia of chronic kidney disease is the use of erythropoiesis-stimulating agents (ESAs). ESAs available in the United States include epoetin alfa and darbepoetin alfa (Aranesp). The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-DOQI) guidelines recommend a target hemoglobin in the range of 11 to 12 g/dL, and the hemoglobin should not exceed 13 g/dL. [18] These goals are associated with lower mortality and less frequent hospitalization rates.

Several trials have been conducted to provide more information regarding the use of ESAs and hemoglobin targets. The Trial to Reduce Cardiovascular Events With Aranesp® Therapy (TREAT) resulted in two reports raising concern about the current use of target-based strategies in managing anemia of chronic kidney disease. The initial report indicated an increased risk of stroke and no reduction in the risk of death or a cardiovascular or renal event with darbepoetin alfa. [21]

The second report noted that when doses of darbepoetin alfa were increased to meet target hemoglobin levels in patients with a poor initial hematopoietic response, the subsequent risk of death or cardiovascular invents increased. [22] (See Cardiovascular disease under Complications of Anemia of Chronic Disease and CKD.)

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