Hypertension following erythropoietin (EPO) in chronic kidney disease
- Wajeh Y Qunibi, MD
Wajeh Y Qunibi, MD
- Professor of Medicine
- University of Texas Health Sciences Center
- William L Henrich, MD, MACP
William L Henrich, MD, MACP
- University of Texas Health Science Center at San Antonio
- Section Editors
- Steve J Schwab, MD
Steve J Schwab, MD
- Editor-in-Chief — Nephrology
- Section Editor — Dialysis
- University of Tennessee Health Science Center
- George L Bakris, MD
George L Bakris, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
Hypertension is a common adverse effect of erythropoietin (EPO) treatment that is observed among patients with chronic kidney disease (CKD) and even among healthy subjects who receive erythropoietin [1-3]. Hypertension in such patients may developed de novo or may worsen after introducing erythropoietin. However, since hypertension in CKD patients may be due to several factors including volume overload, erythropoietin-related hypertension should be a diagnosis of exclusion.
This topic reviews hypertension related to erythropoietin among CKD patients. Other issues related to erythropoietin among CKD patients, including hemoglobin (Hb) targets, are addressed elsewhere. (See "Erythropoietin for the anemia of chronic kidney disease among predialysis and peritoneal dialysis patients" and "Erythropoietin for the anemia of chronic kidney disease in hemodialysis patients" and "Anemia of chronic kidney disease: Target hemoglobin/hematocrit for patients treated with erythropoietic agents".)
EPIDEMIOLOGY AND RISK FACTORS
Overall, approximately 20 to 30 percent of patients who receive erythropoietin intravenously for the anemia of CKD develop an elevation in diastolic pressure of 10 mmHg or more [4,5]. A phase-III trial involving 251 hemodialysis patients found that 35 percent of patients developed an increase in their diastolic blood pressure (BP) of at least 10 mmHg, or required an increase in their antihypertensive agents after three months of ESA therapy. Moreover, 44 percent of patients who were not hypertensive at baseline also had an increase in diastolic BP of at least 10 mmHg, and one-third of them were started on antihypertensive therapy . However, much of the evidence that erythropoietin contributes to hypertension in CKD patients was derived from a series of meta-analyses [5,7]. As an example, in one meta-analysis that included six randomized trials comparing erythropoietin versus placebo or no erythropoietin (n = 387 patients), patients who did not receive erythropoietin had a lower risk of hypertension (relative risk [RR] 0.50, 95% CI 0.33-0.76).
Another meta-analysis from the Cochrane Collaboration that included four controlled trials in nondialysis CKD patients showed a 26 percent higher risk of hypertension in erythropoietin-treated patients, compared with no erythropoietin or placebo, but the effect was not statistically significant .
Putative risk factors for erythropoiesis-stimulating agent (ESA)-associated hypertension include the following:
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