The Janus faces of ESAs: caveat Chimaera!
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NEPHROLOGY - REVIEW
The Janus faces of ESAs: caveat Chimaera! Hugo Penny • Daniel Leckstro¨m David Goldsmith
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Received: 21 July 2012 / Accepted: 8 August 2012 / Published online: 13 September 2012 Ó Springer Science+Business Media, B.V. 2012
Abstract Patients with chronic kidney disease (CKD) have a Janus quality as they look back whence they came in developing CKD and, in some cases, also look forwards to a potential kidney transplant with the attendant promise of improvement in quality and often quantity of life. Making the most of this often unique opportunity is key—maximising the chance that the engraftment starts as a success, and then later, preserving good kidney transplant function for as long as possible. Two recently published, independently conceived and executed studies are relevant to both aspects of this quest and thus to all kidney transplant recipients (KTRs). Both trials also simultaneously stoke and quench the continuing, heated debates over target haemoglobin (Hb) levels, and the use of erythropoiesis-stimulating agents (ESAs), in CKD patients. One study—of acute, high-dose ESA administration—adds to the plethora of adverse safety signals swirling around the use of ESAs while surprisingly also showing renal function benefits at 12 months. The other study features chronic lowerdose ESA use in stable KTRs with anaemia and impaired renal function and not only purports to show a salutary effect on 2-year renal function outcomes (and thus reducing ‘‘return to dialysis’’ rates), but also rebuts the now widely accepted current notion that by H. Penny D. Leckstro¨m D. Goldsmith (&) King’s Health Partners AHSC, Wing Guy’s Hospital, 6th Floor, Borough, London SE1 9RT, UK e-mail: [email protected]
chronic use of ESAs to target full Hb correction/higher Hb values in anaemic CKD patients, we are potentially causing harm. Keywords Epoetin Erythropoietin Mortality Transplantation Anemia
Introduction In ancient Roman times, Janus was the god of beginnings, transitions, new things—thence also of gates, doorways, endings and time. He was typically presented pictorially as a two-faced god since he looked both to the future and the past [1]. The Romans dedicated the month of January to Janus and felt that how a new opportunity started was indicative of its eventual outcome (i.e. an omen). A Chimaera was, according to Greek mythology, a monstrous firebreathing female ‘‘she-goat’’ creature of Lycia in Asia Minor, composed of the parts of three animals: a lion, a serpent and a goat [2]. Sighting a chimaera was also an omen—of storms, eruptions and other natural disasters. Patients with chronic kidney disease (CKD) have a Janus quality too as they look back whence they came in developing CKD and, in some cases, also look forwards, to a potential kidney transplant with the attendant promise of improvement in quality and often quantity of life. Making the most of this often unique opportunity is key—maximising the chance that the
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engraftment starts as a success, and then later, pres
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