Comparison of Dosage Requirement of Erythropoietin Stimulating Agent (ESA) in Maintenance of Hemoglobin Concentration in patients undergoing twice weekly versus thrice weekly Hemodialysis in Pakistani Population

Anemia is one of the major complications of patients with chronic kidney disease (CKD) undergoing hemodialysis (HD) and is associated with left ventricular hypertrophy and also increases morbidity and mortality. Anemia in patients with CKD can be due to two major reasons; iron deficiency or erythropoietin insufficiency. Erythropoietin Stimulating Agent (ESAs) administration is the mainstay in treating anemia if the patient is iron sufficient. However, higher doses of ESAs have been associated with increased cerebrovascular and cardiovascular events. We conducted this study to see how much erythropoietin is required in our setting in iron sufficient patients to maintain hemoglobin(Hb)  level and the effect of dialysis frequency on ESA doses.  Methods and Findings: A cross-sectional study was conducted at the Department of Nephrology at Ziauddin University Hospital. Patients’ charts were reviewed for Hb levels and doses of ESA to maintain Hb between 10-12 mg/dl. Patients were excluded if they had iron deficiency, malignancy, were on immunosuppressive agents, had renal transplant, and with Hb >12 mg/dl or <10 mg/dl and their ferritin levels, transferrin saturation, hemoglobin concentration, frequency of hemodialysis and ESA dosage were monitored. We also compared these variables between patients undergoing hemodialysis thrice weekly with those undergoing hemodialysis twice a week. A total of 105 patients were analyzed. 24 were excluded as they did not match the inclusion criteria. 81 patients were included in the study. 36 (44.4%) were males and 45 (55.6%) were females. Mean age of the patient was 56.47 ± 11.72 years. The average dose of ESA was 106.91 ± 61.47 for patients undergoing hemodialysis thrice weekly and 183.94 ± 116.71 for patients undergoing hemodialysis twice a week. Significant difference was found to exist between dosage of patients undergoing thrice weekly dialysis versus twice weekly dialysis(p=<0.001).  Our study has limitations. First our study only looked at Hb levels, iron stores and dosages of ESA, while other factors like Parathyroid Hormone(PTH) levels and Vitamin B12 were not considered that may have a role in anemia of chronic renal disease. In addition, it was a study limited to one center only and a multicenter trial should be taken to validate the results. We have reported one aspect of dialysis vintage i.e.  high ESA dosage requirement Conclusion: We found that patients undergoing hemodialysis three times a week require recommended dosage of ESA; however those undergoing hemodialysis less than three times a week require higher dosage of ESA to maintain Hb level. Here we report significant effect of hemodialysis on ESA dosage to maintain same level of Hb.