Treating anemia early in renal failure patients slows the decline of renal function: A randomized controlled trial

Background. Erythropoietin is known to improve outcomes in patients with anemia from chronic renal disease. However, there is uncertainty about the optimal timing of initiation of erythropoietin treatment in predialysis patients with non-severe anemia. Methods. We conducted a randomized controlled trial of early versus deferred initiation of erythropoietin in nondiabetic predialysis patients with serum creatinine 2 to 6 mg/dL and hemoglobin 9 to 11.6 g/dL. The early treatment arm was immediately started on 50 U/kg/wk of erythropoietin alpha with appropriate titration aiming for hemoglobin of 13 g/dL. The deferred treatment arm would start erythropoietin only when hemoglobin decreased to < 9 g/dL. The primary end point was a composite of doubling of creatinine, renal replacement, or death. Results. Eighty-eight patients were randomized (early treatment N = 45, deferred treatment N = 43) and followed for a median of 22.5 months. During follow-up, 13 versus 23 patients reached the primary end point in the two arms, respectively (log-rank P = 0.0078). The relative hazard for reaching an end point was 0.42 (P = 0.012). Adjusting for baseline serum creatinine, the adjusted relative hazard was 0.37 (P = 0.004), while the risk increased 2.23-fold (P < 0.001) per 1 mg/dL higher creatinine at baseline. The benefit was similar regardless of the baseline hemoglobin and proteinuria. No patients had any severe adverse events. Conclusion. Early initiation of erythropoietin in predialysis patients with non-severe anemia significantly slows the progression of renal disease and delays the initiation of renal replacement therapy.