Management of anemia with quotidian hemodialysis

Most patients with end-stage renal disease have chronic anemia caused by inadequate erythropoietin (EPO) synthesis and require therapy with exogenous EPO to maintain recommended hematocrit and hemoglobin levels.

The London Daily/Nocturnal Hemodialysis Study compared anemia control among patients on either short daily, long nocturnal, or conventional thrice-weekly hemodialysis (HD) therapy. Patients were administered iron, either orally (900 mg/d) or intravenously (50 to 125 mg every 1 to 4 weeks), to maintain serum ferritin levels at greater than 45 ng/mL (100 microg/L) or transferrin saturations greater than 20%. EPO was administered by subcutaneous injection at frequencies ranging from twice weekly to once every second week to maintain hemoglobin levels within the target range of 11 to 12 g/dL (110 to 120 g/L).

Both the daily HD and nocturnal HD study groups showed increased hemoglobin levels at later times compared with baseline levels, although only nocturnal HD patients had a statistically significant increase in hemoglobin levels at 18 months (11.94 g/dL [119.4 g/L] versus 10.95 g/dL [109.5 g/L] at baseline; P = 0.047). Both the daily HD and control groups showed a trend for decreased EPO dose requirements at later times compared with baseline, although these decreases were not statistically significant. The nocturnal HD group showed increased EPO dose requirements, although not statistically significant.

Quotidian HD is associated with an increased quantity of blood loss that can account for some of the increased requirements in EPO dose. Additional studies with larger numbers of patients are needed to fully elucidate the effects of quotidian HD on anemia.