Is there a value of erythropoietin in pre‐dialysis patients?

Summary: The use of erythropoietin (EPO) in anaemic dialysis patients is now well established: there is still some doubt, however, of its role in pre‐dialysis patients. This was based on initial animal work that showed accelerated decline in the renal function. Since then several studies in pre‐dialysis patients have shown that it is both effective and safe. For patients who are anaemic (haematocrit <30%), there is marked increase in their subjective well‐being and ability to perform physical work. There is therefore no reason to deny EPO therapy to pre‐dialysis patients who are symptomatic from anaemia. the evidence clearly shows that contrary to animal work, there is no accelarated progression in renal failure. There is is some evidence that it may even delay the need for dialysis in children and possibly in some adults. In patients who have rapid progression, it is more related to untreated hypertension. Some 30‐40% of EPO treated pre‐dialysis patients need initiation of or increase in anti‐hypertensive therapy. Subcutaneous (s.c.) self administration (1–3/week) is convenient and accepted by patients. Detection and correction of iron deficiency plays an essential role in maximizing the success of EPO therapy. Oral iron is convenient and satisfactory in most patients. Ferrokinetic studies reveal similar findings as in dialysis patients. There is increase in effective erythropoeisis, except in patients who are on azathioprine (pre‐dialysis failing transplants) where the effect may be blunted by an increase in ineffective erythropoeisis. Erythropoietin improves the quality of life in predialysis patients. the most important side effect is development of hypertension, which can be controlled.