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Erythropoiesis-Stimulating Agents for Anemia of Chronic Kidney Disease: Systematic Review and Economic Evaluation

Last updated: March 11, 2008
Issue: 106
Result type: Report


Erythropoiesis-stimulating agents (ESA), epoetin alpha (Eprex ®, Janssen-Ortho), darbepoetin (Aranesp ™, Amgen), and epoetin beta (NeoRecormon ®, Roche)


Adult patients with anemia of chronic kidney disease (CKD) who need or do not need dialysis.


ESAs are routinely used to treat anemia of chronic kidney disease (CKD), especially in patients requiring dialysis. Increasingly, higher doses of ESA are being used to attain higher hemoglobin (Hb) target levels. There is uncertainty about the impact of this approach on the health system.

Methods and Results

Randomized controlled trials (RCTs) that included anemic adults with CKD receiving epoetin (alpha or beta), darbepoetin or “management without ESA” (no ESA) and compared clinical outcomes and harms on the basis of Hb targets and method of delivery were identified through a systematic review. A cost-utility analysis from the perspective of the Canadian public health care system and a lifetime time horizon was conducted. The budget impact to the provincial health care system was estimated if patients were treated to an intermediate Hb target and if the subcutaneous (SC) rather than the intravenous (IV) route of administration of ESA was used.

Implications for Decision Making

  • Health outcomes are improved, but some uncertainty remains. ESA resulted in lower observed cardiovascular mortality, but all-cause mortality was not affected. The impact on health-related quality of life was modest, and most trials did not provide a complete report of these measures.
  • Intermediate and low targets are optimal. Low (90 to 105 g/L) Hb target strategies represent the least costly and second most effective option. Intermediate Hb target (110 g/L) strategies produce the largest number of quality-adjusted life years (QALYs) at an additional cost per patient lifetime (C$21,000 to C$27,000 per patient lifetime compared with the low Hb target in non-dialysis-dependent and dialysis-dependent adult CKD).
  • Route of administration and Hb target will affect health care budgets. For dialysis-dependent patients, the estimated cost of treating anemia to an intermediate Hb target is C$9,394 per patient per year on dialysis. If SC epoetin is used instead of IV (or if darbepoetin is used via either route), costs could be reduced to C$6,577 per patient per year. Altering the Hb target to a low strategy would result in cost savings of C$35 million to C$49 million per year compared with the intermediate target.

This summary is based on a comprehensive health technology assessment available from CADTH’s web site ( Tonelli M, Klarenbach S, Wiebe N, Shrive F, Hemmelgarn B, Manns B. Erythropoiesis-Stimulating Agents for Anemia of Chronic Kidney Disease: Systematic Review and Economic Evaluation