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Ovid: Oxford Handbook of Dialysis

Editors: Levy, Jeremy; Morgan, Julie; Brown, Edwina Title: Oxford Handbook of Dialysis, 2nd Edition Copyright ©2004 Oxford University Press > Table of Contents > Part 8 – Complications of ESRD: anaemia > Erythropoietin: initiating therapy Erythropoietin: initiating therapy

  • Patients must have adequate iron stores prior to starting EPO or darbepoietin. Serum ferritin should be >200 µg/l and transferrin saturation >20%. Oral iron is poorly tolerated and intravenous iron infusions are often needed.
  • Iron stores can be depleted rapidly once erythropoiesis is induced. Ferritin levels therefore need to be closely monitored and further iron replacement given as needed.
  • BP should be well controlled. Severe hypertension and fits were a complication of starting EPO when it was first introduced, but are rarely seen with current dosage regimens, with slower rises in Hb levels.
  • Starting dose of EPO should be 80–120 units/kg/week (typically 6000 units per week) in two or three divided doses. Intravenous doses need to be increased by 30–50% (average 9000 units per week).
  • Starting dose of darbepoietin is 0.45 µg/kg weekly either SC or IV.
  • If converting patient from EPO to darbepoietin, divide total weekly dose of EPO by 200, and administer IV or SC once a week.

Titrating dose

  • Target Hb should be reached in 3–4 months (increase in Hb of approx 1 g/dl per month).
  • Most patients will require approx 6000–9000 units/week during the maintenance phase, but this is highly variable.
  • Hb should be monitored every 2–4 weeks after initiating therapy or after a change in dose.
  • If Hb rises too fast, temporarily withhold EPO or darbepoietin. Hb should fall about 1 g/dl per month. Reinstate EPO or darbepoietin at a dose approx 25% below previous dose.
  • Decrease dose by between 25 and 50% if Hb increases more than 2.5 g/dl in a 4-week period.
  • Increase dose of EPO or darbepoietin by approx 25% if increase in Hb < 1g/dl over 4 weeks and iron stores are adequate.

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