Anemia management in dialysis patients: a PIVOT and a new path?

PURPOSE OF REVIEW: We will examine the current and future options in management of anemia in dialysis patients focusing on recent trials in iron supplementation and alternatives to erythropoietin-stimulating agents (ESAs). RECENT FINDINGS: We review the literature on Erythropoietin (EPO)-stimulating agents, focusing on the risk benefits of various options available. We review the recent practice changing trial in iron supplementation in dialysis patients with chronic kidney disease and movements in the research on alternatives to EPO-stimulating agents primarily hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs). SUMMARY: ESAs constitute the mainstay of treatment of anemia in dialysis and evidence does not support the preference of any one type over the other. But concerns exist about the cardiovascular safety of supra-physiological ESA levels. Iron supplementation has been shown to be a well tolerated method to decrease ESA doses while maintaining hemoglobin levels and recent evidence should result in a revisiting of the guidelines for iron supplementation. HIF-PHIs are potentially safe alternatives to ESAs that correct and maintain hemoglobin while maintaining physiological levels of erythropoietin. Ongoing phase III trials for these drugs will likely answer questions of long-term safety regarding these drugs.

The outcome of treating ESBL infections with carbapenems vs. non carbapenem antimicrobials.

BACKGROUND: In India where the prevalence of extended spectrum beta lactamase (ESBL) producing organisms among gram negative organisms is 60-70% and Ertapenem was unavailable at the beginning of this study, exclusive use of Group 2 Carbapenems (Imipenem and Meropenem) for treatment raises issues of cost and development of resistance. Therefore the role of non-Carbapenem alternatives, chiefly Betalactam + Betalactamase inhibitors (BL-BLI) was explored in this prospective observational study at a private tertiary care teaching hospital. PATIENTS AND METHODS: 522 consecutive in door patients from the period between June 2006 to March 2007and June 2008 to December 2008, who had true infections with ESBL producing organisms were enrolled in the study. Antimicrobials were prescribed or changed by the treating physicians on the basis of the nature and severity of infection, the susceptibility of the organism and the affordability of the patient. Patients who received a Carbapenem at any time during treatment were considered in the Carbapenem group. Those who never received a Carbapenem at any time during treatment were considered in the non-Carbapenem group. RESULTS: Of the 522 infections, 287 were urinary tract infections, 60 were skin structure infections, 60 were bacteremias, 55 were hospital acquired pneumonias, 31 were intra-abdominal infections and 29 were other infections. There were 351 E. coli, 119 K. pneumoniae, 23 K. oxytoca, 16 Enterobacter aerogenes, 5 Kozoanae, 4 Enterobacter agglomerans, 3 Citrobacter freundi, 1 E. cloacae, 1 Enterobacterspp. and 1 Morgenella morganii isolates. Clinical outcomes were available for 486 patients. 339 patients who were in the non-Carbapenem group and who might have had less serious infections had a clinical success rate of 79.6%. 147 patients who were in the Carbapenem group and who might have had more serious infections had a clinical success rate of 85.71%. CONCLUSIONS: It is possible to successfully treat at least the less serious infections due to ESBL producing gram negative organisms with non-Carbapenem antimicrobials. This will not compromise outcomes but will likely result in restricting the use of Carbapenems which may help preserve their efficacy against increasingly resistant organisms.