Effects of haemoglobin normalization on quality of life and cardiovascular parameters in end‐stage renal failure
01 Sep 2000-Nephrology Dialysis Transplantation (Oxford University Press)-Vol. 15, Iss: 9, pp 1425-1430
TL;DR: There may be a significant haemodynamic and symptomatic advantage in maintaining a physiological [Hb] in haemodialysis patients, and a substantially higher dose of epoetin is required to maintain this level.
Abstract: BACKGROUND: The optimal haemoglobin concentration ([Hb]) for patients with end-stage renal failure is uncertain. In particular, it is unclear whether Hb normalization may be an advantage to such patients who are otherwise well. METHODS: A prospective, randomized, double-blind cross-over study was completed in 14 haemodialysis patients (12 male) aged between 23 and 65 years over a period of 18 months, using a variety of measures to examine the effect of epoetin at target [Hb] of 10 g/dl ([Hb](10)) and 14 g/dl ([Hb](14)). Patients were randomized to maintain one or other of the target levels for 6 weeks before being crossed over to the alternative [Hb]. Baseline data (mean [Hb]: 8.5+/-0.2 g/dl) were also included selectively. Six patients were known to be hypertensive. Comparisons were made between 24-h ambulatory blood pressure levels (ABP), echocardiographic findings and estimates of blood volume (BV), plasma volume (PV) and Hb mass. Quality of life estimates were obtained using the Sickness Impact Profile (SIP), and epoetin dosage requirements at target [Hb] were assessed. RESULTS: Daytime and nocturnal ABP (systolic and diastolic) were not different at the respective target [Hb], although nocturnal diastolic levels were higher compared with baseline (73+/-4 mmHg) at both [Hb](10) (83+/-3, P:<0.01) and [Hb](14) (81+/-6, P:<0.05). Significant reductions in cardiac output (5.2+/-0.3 vs 6.6+/-0.5 l/min, P:<0.01) and left ventricular end-diastolic diameter (4.8+/-0.2 vs 5.2+/-0.2 cm, P:<0. 001) were found at [Hb](14) compared with [Hb](10). Left ventricular mass index was correlated with both PV (P:<0.001) and BV (P:<0.01), but not with Hb mass. The PV decreased as the [Hb] rose (P:<0.001) but BV remained unchanged. Quality of life was significantly improved at [Hb](14) compared with [Hb](10) for both total score (6. 5+/-1.7 vs 13.4+/-3.0, P:=0.01) and psychosocial dimension score (5. 4+/-1.9 vs 15.4+/-4.0, P:<0.01). The maintenance weekly dose of epoetin required was 80% higher at [Hb](14) compared with [Hb](10) (P:<0.001). CONCLUSION: These data suggest there may be a significant haemodynamic and symptomatic advantage in maintaining a physiological [Hb] in haemodialysis patients. Although untoward effects were not identified in this study at [Hb](14), a substantially higher dose of epoetin is required to maintain this level.
Citations
More filters
Journal Article•
TL;DR: Pretransplant hemoglobin level does not affect the outcome of kidney transplant, except for creatinine levels at 1 year, and posttrans transplant hemoglobin levels were higher in group B (> 10 g/dL) compared with group A (< 10g/dL), (P = .019).
Abstract: OBJECTIVES
We investigated the effect of pretransplant hemoglobin level on the outcome of kidney transplant.
PATIENTS AND METHODS
Patients were divided in 2 groups: group A < 10 g/dL (80 patients; PTHb < 10 g/dL), and group B > 10 g/dL (69 patients; PTHb = 10 g/dL), and were matched regarding donor age, recipient sex, blood group, donor recipient HLA, and Cytomegalovirus status.
RESULTS
The frequency of acute rejection, together with the timing of rejection, the need for antithymocyte globulin Fresenius rescue therapy, infection rate, and posttransplant surgical complications were comparable between both groups. While the 1-year actuarial patient and graft survival rates, delayed graft function, and slow graft function rates were comparable between both groups, longer hospital stay was required for group B (> 10 g/dL) patients (P = .005). Mean serum creatinine levels upon discharge (P = .02), at 6 months (P = .05), and 1 year (P = .02) after discharge were higher in group B (> 10 g/dL) patients. While posttransplant hemoglobin levels were lower than pretransplant levels, they were higher in group B (> 10 g/dL) compared with group A (< 10 g/dL), (P = .019).
CONCLUSIONS
Pretransplant hemoglobin level does not affect the outcome of kidney transplant, except for creatinine levels at 1 year.
2 citations
Cites background from "Effects of haemoglobin normalizatio..."
...Others suggested that physiologic hemoglobin may be advantageous for hemodialysis patients, as evidenced by progressive improvement in echocardiographic parameters upon hemoglobin normalization, with a special reference to hypertension, which was not aggravated at higher target hemoglobin (9)....
[...]
TL;DR: Intravenous iron utilization in iron deficiency, anemia of chronic inflammation (ACI), functional iron deficiency (FID), and anemia associated with chronic kidney disease, heart failure, pregnancy, inflammatory bowel disease and cancer are discussed.
Abstract: Iron is an abundant element that is essential for multiple biologic processes. Iron metabolism is not entirely understood, but since the discovery of hepcidin, much progress has been made especially in the last five years. This article is intended to enhance clinician understanding of iron metabolism which may inform decisions about parenteral iron use in iron-restricted erythropoiesis (IResE). This article briefly discusses intravenous (IV) iron utilization in iron deficiency, anemia of chronic inflammation (ACI), functional iron deficiency (FID), and anemia associated with chronic kidney disease, heart failure, pregnancy, inflammatory bowel disease and cancer. Oral iron therapy is valuable in mild to moderate pure iron deficiency. Intravenous iron is required when a prompt response is needed in severe pure iron deficiency. ACI is a hypoferremic state resulting from altered iron metabolism. In ACI, IV iron is needed to overcome the blocking effects of hepcidin on intestinal absorption. ESAs stimulate erythropoiesis increasing iron utilization. This surge in iron requirement can result in FID, especially when ESAs are used in patients with ACI. Intravenous iron is required to treat or avoid iron deficiency in FID when inflammation is present. Parenteral iron maximizes ESA response and can make using erythropoiesis-stimulating agents (ESAs) safer by being ESA sparing. The complex and seemingly ubiquitous nature of iron in humans and the inadequate methods of assessment of iron status in inflammatory states means clinical and laboratory monitoring and individualization of care remain essential. The decision to administer intravenous iron is complex as it often lacks robust consensus guidelines; despite this we can expect utilization of these products to increase as they are safe, effective and necessary.
1 citations
Cites background from "Effects of haemoglobin normalizatio..."
...Tobili et al. demonstrated that in anemia of heart failure, IV iron might even decrease brain natriuretic peptide (BNP) levels and improve left ventricular ejection fraction (LVEF), 6-minute walk distance, and renal function [70]....
[...]
...Higher hemoglobin levels in HFrEF may increase blood viscosity, systemic vascular resistance, raise the left ventricular afterload and cause the LVEF to decrease....
[...]
...Surprisingly, anemic heart failure patients have been found to have better left ventricular ejection fractions (LVEF), presumably due to lower blood viscosity....
[...]
...An increase in hemoglobin over time is associated with decreased LVEF [59-62]....
[...]
...In patients with HFrEF and CKD, hemoglobin increases have been demonstrated to decrease LVEF and cardiac output [60] proportionally....
[...]
TL;DR: Individualized strategies for managing renal anaemia with erythropoiesis-stimulating agents (ESAs) need to be advanced to achieve the haemoglobin target at the lowest ESA dose while avoiding significant fluctuations inHaemoglobin concentrations and persistently low or high concentrations.
Abstract: Individualized strategies for managing renal anaemia with erythropoiesis-stimulating agents (ESAs) need to be advanced. Recent outcomes from clinical studies prompted a narrowing of the guideline-recommended haemoglobin target (11–12 g/dL) due to increased mortality and morbidity when targeting higher haemoglobin concentrations. Maintaining a narrow target is a clinical challenge, as haemoglobin concentration tends to fluctuate. The goal of individualized treatment is to achieve the haemoglobin target at the lowest ESA dose while avoiding significant fluctuations in haemoglobin concentrations and persistently low or high concentrations. This may require changes to the ESA dose and dosing frequency over the course of treatment.
1 citations
Cites background from "Effects of haemoglobin normalizatio..."
...Furthermore, observational and some prospective studies reported that higher or normalized Hb levels in CKD patients were not associated with increased risk of adverse outcomes [2,16–18] and might improve mortality and morbidity outcomes, particularly cardiovascular outcomes, and QOL [14,18–23]....
[...]
TL;DR: Substitution of recombinant human erythropoietin (r-HuEPO) is the most effective therapy and the goal is a stable haemoglobin level >11 g/dl.
Abstract: Anemia is as a frequent complication in patients with chronic kidney disease, which gains in importance in the treatment of patients with renal disease. The main cause of renal anemia is the inadequately low production of endogenous erythropoietin. Often the patients develop an additional absolute or functional iron deficiency, which complicates the diagnostic and therapeutic procedures. Substitution of recombinant human erythropoietin (r-HuEPO) is the most effective therapy. The goal is a stable haemoglobin level >11 g/dl. An often additional existing iron deficiency should be balanced adequately according to the guidelines. With consequent and early treatment morbidity, mortality, and quality of life can be effectively improved.
1 citations
Cites background from "Effects of haemoglobin normalizatio..."
...Darüber hinaus führt eine konsequente Behandlung auch zu einer Verzögerung der Progression der Nierenerkrankung und des Zeitpunkts der Dialysepflichtigkeit [29, 30, 31, 32]....
[...]
References
More filters
TL;DR: In this article, the authors developed the Sickness Impact Profile (SIP), a behaviorally based measure of health status, and evaluated its reliability and validity using multitrait-multimethod technique.
Abstract: The final development of the Sickness Impact Profile (SIP), a behaviorally based measure of health status, is presented. A large field trial on a random sample of prepaid group practice enrollees and smaller trials on samples of patients with hyperthyroidism, rheumatoid arthritis and hip replacements were undertaken to assess reliability and validity of the SIP and provide data for category and item analyses. Test-retest reliability (r = 0.92) and internal consistency (r - 0.94) were high. Convergent and discriminant validity was evaluated using the multitrait--multimethod technique. Clinical validity was assessed by determining the relationship between clinical measures of disease and the SIP scores. The relationship between the SIP and criterion measures were moderate to high and in the direction hypothesized. A technique for describing and assessing similarities and differences among groups was developed using profile and pattern analysis. The final SIP contains 136 items in 12 categories. Overall, category, and dimension scores may be calculated.
4,283 citations
Book•
01 Feb 1994
TL;DR: In this paper, the principles of exercise testing and interpretation are presented for exercise testing in the Libros de Medicina (Patologia) 5/e - Patologia - 139,00
Abstract: Principles of Exercise Testing and Interpretation, 5/e - Libros de Medicina - Patologia - 139,00
2,331 citations
TL;DR: In patients with clinically evident congestive heart failure or ischemic heart disease who are receiving hemodialysis, administration of epoetin to raise their hematocrit to 42 percent is not recommended.
Abstract: Background In patients with end-stage renal disease, anemia develops as a result of erythropoietin deficiency, and recombinant human erythropoietin (epoetin) is prescribed to correct the anemia partially. We examined the risks and benefits of normalizing the hematocrit in patients with cardiac disease who were undergoing hemodialysis. Methods We studied 1233 patients with clinical evidence of congestive heart failure or ischemic heart disease who were undergoing hemodialysis: 618 patients were assigned to receive increasing doses of epoetin to achieve and maintain a hematocrit of 42 percent, and 615 were assigned to receive doses of epoetin sufficient to maintain a hematocrit of 30 percent throughout the study. The median duration of treatment was 14 months. The primary end point was the length of time to death or a first nonfatal myocardial infarction. Results After 29 months, there were 183 deaths and 19 first nonfatal myocardial infarctions among the patients in the normal-hematocrit group and 150 deat...
1,944 citations
TL;DR: It is concluded that clinical and echocardiographic cardiovascular disease are already present in a very high proportion of patients starting ESRD therapy and are independent mortality factors.
1,255 citations
TL;DR: Overstretching appears to be coupled with oxidant stress, expression of Fas, programmed cell death, architectural rearrangement of myocytes, and impairment in force development of the myocardium.
Abstract: To determine the effects of loading on active and passive tensions, programmed cell death, superoxide anion formation, the expression of Fas on myocytes, and side-to-side slippage of myocytes, papillary muscles were exposed to 7-8 and 50 mN/mm2 and these parameters were measured over a 3-h period. Overstretching produced a 21- and a 2.4-fold increase in apoptotic myocyte and nonmyocyte cell death, respectively. Concurrently, the generation of reactive oxygen species increased 2.4-fold and the number of myocytes labeled by Fas protein 21-fold. Moreover, a 15% decrease in the number of myocytes included in the thickness of the papillary muscle was found in combination with a 7% decrease in sarcomere length and the inability of muscles to maintain stable levels of passive and active tensions. The addition of the NO-releasing drug, C87-3754, prevented superoxide anion formation, programmed cell death, and the alterations in active and passive tensions with time of overloaded papillary muscles. In conclusion, overstretching appears to be coupled with oxidant stress, expression of Fas, programmed cell death, architectural rearrangement of myocytes, and impairment in force development of the myocardium.
642 citations