Increased mortality in haemodialysis patients administered high doses of erythropoiesis-stimulating agents: a propensity score-matched analysis

Nephrol Dial Transplant. 2018 Apr 1;33(4):690-699. doi: 10.1093/ndt/gfx269.


Background: Erythropoiesis-stimulating agents (ESAs) are widely used to treat anaemia in patients with chronic kidney disease. The issue of ESA safety has been raised in multiple studies, with correlates derived for elevated cancer incidence and mortality. Whether these associations are related to ESA dose or the typology of the patient remains obscure.

Methods: A multicentre, observational retrospective propensity score-matched study was designed to analyse the effects of weekly ESA dose in 1679 incident haemodialysis (HD) patients. ESA administration was according to standard medical practice. Patients were grouped as quintiles, according to ESA dose, in order to compare mortality and hospitalization data. Using propensity score matching (PSM), we defined two groups of 324 patients receiving weekly threshold ESA doses of either > or ≤8000 IU.

Results: Kaplan-Meier survival curves indicated significant increases in the risk of mortality in patients administered with high doses of ESAs (>8127.4 IU/week). Multivariate Cox models identified a high ESA dose as an independent predictor for all-cause and cardiovascular (CV) mortality. Moreover, logistic regression models identified high ESA doses as an independent predictor for all-cause, CV and infectious hospitalization. PSM analyses confirmed that weekly ESA doses of >8000 IU constitute an independent predictor of all-cause mortality and hospitalization, even though the adjusted cohort displayed the same demographic features, inflammatory profile, clinical HD parameters and haemoglobin levels.

Conclusions: Our data suggest that ESA doses of >8000 IU/week are associated with an increased risk of all-cause mortality and hospitalization in HD patients.

Publication types

  • Observational Study

MeSH terms

  • Aged
  • Female
  • Hematinics / administration & dosage
  • Hematinics / adverse effects*
  • Hospitalization / statistics & numerical data*
  • Humans
  • Male
  • Mortality / trends*
  • Prognosis
  • Propensity Score*
  • Renal Dialysis / adverse effects
  • Renal Dialysis / mortality*
  • Renal Insufficiency, Chronic / mortality*
  • Renal Insufficiency, Chronic / therapy
  • Retrospective Studies
  • Survival Rate


  • Hematinics