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Anemia Treatment and Its Clinical Implications in Patients Receiving Hemodialysis Hyporesponsive to Erythropoietin-Stimulating Agents

Year: 2026

Type: article

Abstract: Rationale & Objective Anemia, highly prevalent among patients receiving maintenance dialysis, may be associated with adverse outcomes. This study describes the patient characteristics, anemia treatment patterns, clinical event rates, and health care resource utilization of patients receiving hemodialysis (HD) in the United States and in a subpopulation of patients hyporesponsive to erythropoietin-stimulating agents (ESAs). Study Design Using data from the US Renal Data System, a retrospective, population-based descriptive cohort study of adults with Medicare Parts A and B coverage receiving maintenance HD was conducted. Setting & Participants ESA hyporesponsiveness was defined as ESA Resistance Index ≥2 (ESA units/kg/wk/g hemoglobin/L) or ESA dose ≥450 U/kg/wk (within 8 weeks of index (January 1, 2018). Outcomes Anemia treatments and clinical events were assessed using medical claims during follow-up, until death, loss of Medicare, kidney transplantation, or December 31, 2019. Analytical Approach Outcome rates were calculated as number of events divided by follow-up time with 95% confidence intervals based on Poisson distribution. Results Of the overall prevalent HD population (N = 209,408), 20,223 were ESA hyporesponders. Relative to the overall prevalent HD population, the ESA hyporesponder subpopulation had a higher rate of red blood cell transfusion events (91.1 [95% CI, 90.1-92.2] vs 32.4 [95% CI, 32.2-32.6] per 100 person-years [PY]), thromboembolic events (80.7 [95% CI, 79.3-82.2] vs 71.0 [95% CI, 70.6-71.4] per 100 PY), major adverse cardiovascular events (30.2 [95% CI, 29.6-30.9] vs 20.3 [95% CI, 20.2-20.5] per 100 PY), gastrointestinal erosions (61.8 [95% CI, 60.6-63.0] vs 40.2 [95% CI, 40.0-40.5] per 100 PY), and all-cause mortality (26.2 [95% CI, 25.6-26.8] vs 16.9 [95% CI, 16.8-17.1] per 100 PY). Hospitalizations occurred more frequently in the ESA hyporesponder subpopulation (2.45 vs 1.56 per PY) than in the overall prevalent HD population. Limitations This study was not designed to determine causality. Conclusions The ESA hyporesponder subpopulation had a high burden of red blood cell transfusion use, clinical events, and health care resource utilization. Plain-Language Summary Most patients receiving dialysis have anemia, which requires treatment. This study analyzed information on patients receiving maintenance hemodialysis in the United States and a subgroup of these patients whose anemia responded poorly to erythropoietin-stimulating agents (ESAs). Relative to the overall population of patients, those whose anemia responded poorly to ESAs had more frequent treatment with red blood cell transfusion, more hospitalizations, higher cardiovascular and non-cardiovascular health complications, and higher rates of death. The findings highlight the importance of understanding outcomes in patients whose anemia responded poorly to ESAs and the need to treat these patients appropriately, which may help inform future resource planning for the health care system.

Source: Kidney Medicine

DOI: 10.1016/j.xkme.2026.101269