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Kidney Week

Abstract: TH-PO700

Examining the Magnitude of Erythropoiesis-Stimulating Agent Hyporesponsiveness in Hemodialysis Patients

Session Information

  • Anemia and Iron Metabolism
    November 03, 2022 | Location: Exhibit Hall, Orange County Convention Center‚ West Building
    Abstract Time: 10:00 AM - 12:00 PM

Category: Anemia and Iron Metabolism

  • 200 Anemia and Iron Metabolism


  • Weinhandl, Eric D., Chronic Disease Research Group, Minneapolis, Minnesota, United States
  • Hwang, Yunji, Amgen Inc, Thousand Oaks, California, United States
  • Gilbertson, David T., Chronic Disease Research Group, Minneapolis, Minnesota, United States
  • Petersen, Jeffrey, Amgen Inc, Thousand Oaks, California, United States

Anemia is common in patients undergoing maintenance hemodialysis (HD) and is treated with erythropoiesis-stimulating agents (ESAs) and intravenous iron. ESA hyporesponsiveness is an oft-cited unmet medical need, but the scope of the problem is obscured by complex statistical quantities, including the erythropoietin resistance index (ERI). We analyzed a contemporary, nationally representative cohort to describe anemia-related parameters of HD patients with high ERI and/or chronically low hemoglobin (Hb).


We analyzed CROWNWeb records of HD patients in 2016-2019. The study cohort included 6-month patient-intervals characterized by treatment with either epoetin alfa (EPO) or darbepoetin alfa (DPO), monthly measurements of Hb, and at least one measurement of transferrin saturation (TSAT). We stratified patient-intervals by the cross-classification of normal vs high ERl (definition: ≥20 EPO-equivalent IU/wk/kg/g/dL, where 1 mcg DPO = 250 IU EPO) and transiently vs chronically low Hb (definition: Hb <10 g/dL in every month of the interval). In each stratum, we estimated median values of weekly ESA dose, Hb, ERI, and TSAT.


We identified 7,824,640 patient-intervals. Prevalence of high ERI was 17.2% in single patient-months and 15.6% during 6-month patient-intervals. In both cases, ERI was strongly correlated with weekly ESA dose (R2 = 0.87). In contrast, prevalence of Hb <10 g/dL was 23.0% in single patient-months, whereas prevalence of chronically low Hb was 2.5% during 6-month patient-intervals (table). Among 15.6% of patients with high ERI, 13.8% experienced only transiently low Hb, with median Hb of 10.1 g/dL and median TSAT of 25.0%. Among 2.5% of patients with chronically low Hb, 1.8% experienced high ERI, with median TSAT of 23.0%.


Prevalence of high ERI in HD patients exceeds 15%, mostly due to the scale of ESA dosing, but this overstates the prevalence of chronic anemia hyporesponsive to treatment. Lower TSAT is common in patients with high ERI and/or chronically low Hb, suggesting potential iron deficiency.

 Normal ERIHigh ERI
low Hb
low Hb
low Hb
low Hb
Patient-intervals (row %)83.7%0.7%13.8%1.8%
ESA dose (EPO-equivalent IU/wk)5136862419,80925,106
Hb (g/dL)10.78.910.18.5
ERI (IU/wk/kg/g/dL)3.93.525.033.3
TSAT (%)


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