Wednesday, 11 April 2012

Health experts warn against non-judicious use of erythropoiesis-stimulating agents (ESA) for chronic kidney disease patients as they may cause more harm than good if not prescribed carefully

Syed Akbar
Hyderabad: Health experts warn against non-judicious use of
erythropoiesis-stimulating agents (ESA) for chronic kidney disease
patients as they may cause more harm than good if not prescribed
carefully.

Though leading health institutions around the world including the
American Society of Nephrology describe non-judicious ESA use as a
good example of “unsafe medical practice”, many doctors here continue
to use erythropoiesis-stimulating agents in patients with kidney
disease. ESA not only drains the patient’s health but also his
hard-earned money in Indian setting, they say.

“While ESA could be harmful, its over use is probably pharma company-
or physician- driven. The price range of ESA is Rs 1200 - Rs 5000 a
week for the patient. There is so much profit on writing /dispensing
ESA that there is no place left for evidence-based medicine,” regrets
a senior nephrologist. Clinical trials revealed that chronic kidney
disease patients were likely better off without the use of ESA.

In its latest guidelines for kidney doctors, the American Board of
Internal Medicine suggests against administer of
erythropoiesis-stimulating agents to chronic kidney disease patients
with hemoglobin levels greater than or equal to 10 grams for decilitre
without symptoms of anemia. “ESAs have no survival or cardiovascular
disease benefit and may be harmful. They should be used to maintain
hemoglobin at lowest levels that minimise need for transfusion,” it
points out.

Referring to the new American guidelines, Dr Mohammad Rafay, kidney
specialist at Apollo Hospitals, Hyderguda in the city, said they are
more relevant in the Indian context. The use of ESA should be
re-examined by all nephrologists and each prescription should be
tailored to individual patient needs. Moreover, non-steroidal
anti-inflammatory drugs (NSAIDS) should not be used in people with
hypertension or heart failure or chronic kidney disease of all causes,
including diabetes.

Dr Rafay, who is an American Board-certified internist and
nephrologist, warns that use of NSAIDS can elevate blood pressure,
make antihypertensive drugs less effective, cause fluid retention and
worsen kidney function. It is also not safe to perform routine cancer
screening for dialysis patients with limited life expectancies without
signs or symptoms unless they are transplant candidates. This includes
mammography, colonoscopy, prostate specific antigen testing, and pap
smears. It is neither cost-effective nor does it improve survival.

As dialysis therapy is more readily available now, more patients are
going on dialysis therapy than before. Well-preserved peripheral veins
improve dialysis outcomes in patients with terminal kidney disease.
Health care workers as well as the patients with chronic kidney
disease should be educated about preserving peripheral veins.

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