Use of Erythopoiesis-stimulating agents in CKD patients with cancer

A recent review in KI 2014 discusses this very important question we face in day to day care of CKD patients. If they have active cancer and CKD- what do we do? What is the Hgb target? If they had a past history of cancer- what do we do?

Hazzan et al review these exact questions. Few take home points from the review.

1.       Based on review of oncology literature:- there is an increase in mortality risk with ESA treatment in cancer. This risk is clearly when ESA is used outside the realm of chemotherapy and the risk may depend on type of cancer but data is not clear on that part.

2.       ESA and having cancer itself pose a thromboembolic risk as well.

3.       Progression of cancer- data is not sufficient based on Cochrane systemic reviews with use of ESA

4.       What to do with CKD and ESA use when patient also has cancer?

  Active cancer:- prior initiating ESA- use PRBCs and correct all reversible causes. If ESA to be used, the authors suggest a target of 10g/dl ( more conservative) and have to treat under the APRISE REMS program( usually heme/onc has to do this) and monitoring of embolic events.

What to do with CKD and ESA with patient with past hx of cancer?

If cured:- CKD guidelines of anemia management( but on conservative side)

If not cured:- treat as if they have active cancer- target of 10g/dl.

Take a look at an in-depth review of this topic in KI