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Int Urol Nephrol (2013) 45:761767 DOI 10.1007/s11255-012-0270-5
NEPHROLOGY - REVIEW
The Janus faces of ESAs: caveat Chimaera!
Hugo Penny Daniel Leckstrm
David Goldsmith
Received: 21 July 2012 / Accepted: 8 August 2012 / Published online: 13 September 2012 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 keymaximising 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 studyof acute, high-dose ESA administrationadds to the plethora of adverse safety signals swirling around the use of ESAs while surprisingly also showing renal function benets at 12 months. The other study features chronic lower-dose 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
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 thingsthence 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 re-breathing female she-goat creature of Lycia in Asia Minor, composed of the parts of three animals: a lion, a serpent and a goat [2]....