Fax +41 61 306 12 34 E-Mail karger@karger.ch www.karger.com In-Depth Review Blood Purif 2010;29:1–12 DOI: 10.1159/000245041 Erythropoiesis Stimulatory Agent- Resistant Anemia in Dialysis Patients: Review of Causes and Management Mehmet Kanbay a Mark A. Perazella c Benan Kasapoglu b Mustafa Koroglu b Adrian Covic d a Department of Medicine, Section of Nephrology, and b Department of Internal Medicine, Fatih University School of Medicine, Ankara, Turkey; c Department of Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Conn., USA; d Department of Nephrology Clinic and Dialysis and Transplantation Center, ‘C.I. PARHON’ University Hospital and University ‘Gr T Popa’, Iasi, Romania Introduction The World Health Organization (WHO) defined ane- mia as a hemoglobin (Hb) level of less than 13.0 g/dl for adult males and postmenopausal women and less than 12.0 g/dl for premenopausal women [1]. Based on these criteria, nearly 90% of patients with a glomerular filtra- tion rate (GFR) of less than 25–30 ml/min have anemia [2]. Despite new therapeutic options and treatment strat- egies, anemia remains one of the major complications of chronic kidney disease (CKD), especially in patients un- dergoing chronic hemodialysis (HD) [3]. The presence of anemia in these patients reduces quality of life and con- tributes to symptoms of advanced renal failure, such as fatigue, reduced exercise tolerance, depression and dys- pnea [4]. Moreover, anemia is associated with worsening of cardiovascular morbidity and accelerated rate of kid- ney damage, and it is an independent predictor of mortal- ity in CKD patients [5] . Therefore, successful manage- ment of anemia is a vital part of patient care that may potentially improve clinical outcomes. Although the United States National Kidney Founda- tion Dialysis Outcomes Quality Initiative (NKF-DOQI) Key Words Erythropoiesis stimulatory agent resistance  Anemia  Chronic kidney disease  Erythropoietin  Darbepoetin  Iron deficiency  Inflammation Abstract Despite new therapeutic options and treatment strategies, anemia still remains one of the major complications of chron- ic kidney disease (CKD), especially in patients undergoing chronic hemodialysis for end-stage renal disease. Successful management of anemia is a central part of patient care that may improve clinical outcomes. Although the National Kid- ney Foundation Dialysis Outcomes Quality Initiative (NKF- DOQI) working group reformulated its recommendations by stating that the hemoglobin target in patients receiving erythropoiesis stimulatory agents (ESA) should generally be 11–12 g/dl, this target value can not be achieved in many of them, despite treatment with high doses of ESA. The aim of the present review is to provide an update of the recent lit- erature on causes and possible management of ESA-resis- tant anemia in CKD patients. Copyright © 2009 S. Karger AG, Basel Published online: October 8, 2009 Mehmet Kanbay, MD Gokkusagi Mahallesi, 16. Cadde, No. 16/21 Cevizlidere/Cankaya, Ankara (Turkey) Tel. +90 505 266 88 66, Fax +90 312 441 54 98 E-Mail drkanbay@yahoo.com or mkanbay@fatih.edu.tr © 2009 S. Karger AG, Basel 0253–5068/10/0291–0001$26.00/0 Accessible online at: www.karger.com/bpu