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Open Access Highly Accessed Research article

Mortality in dialysis patients may not be associated with ESA dose: a 2-year prospective observational study

Lawrence P McMahon12*, Michael X Cai2, Sanjeev Baweja2, Stephen G Holt12, Annette B Kent2, Vlado Perkovic3, Murray J Leikis3 and Gavin J Becker3

Author Affiliations

1 Monash University, Melbourne, Australia

2 Department of Renal Medicine, Eastern Health, Melbourne, VIC, Australia

3 Department of Renal Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia

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BMC Nephrology 2012, 13:40  doi:10.1186/1471-2369-13-40

Published: 15 June 2012



Anaemia of chronic kidney disease increases the risk of death and adverse events, but can be managed using erythropoiesis stimulating agents (ESAs). However, recent evidence suggests that targeting a higher haemoglobin concentration ([Hb]) increases mortality risk, and both higher [Hb] targets and ESA doses have been implicated. Nonetheless, a causative role has not been demonstrated, and this potential relationship requires further appraisal in such a complex patient group.


The relationship between the haematopoietic response to ESAs and patient survival in 302 stable, prevalent dialysis patients was explored in a prospective, single-centre study. Clinical and laboratory parameters influencing mortality and ESA resistance were analysed. Patients were stratified into 5 groups, according to their [Hb] and ESA dosage, and were followed for 2 years.


Little difference in co-morbidities between groups was identified. 73 patients died and 36 were transplanted. Initial analysis suggested a direct relationship between mortality and ESA dosage. However, Cox proportional hazards multivariate analysis demonstrated mortality risk was associated only with age (adjusted HR per year: 1.061, 95% CI 1.031-1.092), dialysis duration (adjusted HR: 1.010, 95% CI 1.004-1.016), peripheral vascular disease (adjusted HR: 1.967, 95% CI 1.083-3.576) and CRP (adjusted HR: 1.024, 95% CI 1.011-1.039). Mortality was increased in patients poorly responsive to ESAs (55.5%).


ESA dose does not appear to contribute substantially to mortality risk in dialysis patients. Instead, age and co-morbidities appear to be the critical determinants. A poor response to ESAs is a marker of overall poor health status.

Haemoglobin; ESA; Dialysis; Prevalent; Mortality