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Résumé: L’anémie est un symptôme fréquent chez les patients atteints de maladie rénale chronique (MRC), débutant un traitement par hémodialyse (HD), corrigé par un apport approprié de fer et d’agent stimulant l’érythropoïèse (ASE). L’objectif de cette étude rétrospective est de préciser la correction de l’anémie et ses conséquences sur les manifestations cardiovasculaires fréquentes au cours de la MRC, et en particulier de préciser l’influence du fer intraveineux (F.IV) prescrit en prédialyse. Cent deux patients ont débuté dans le centre le traitement par HD, âge moyen 58,5 (15,9), 70 % d’hommes, 27 % de diabétiques. Quatre-vingt-dix patients ont débuté avec une FAV. L’index de Charlson est 7,3 (3,5). La mortalité à un an est de 3 %. Le taux d’hémoglobine (Hb) au début est de 10,6 (1,7) g/dL et au bout d’un an 11,7 (1,1) g/dL (p <0,0001). La darbepoetin alfa (DA), injectée toutes les deux semaines, l’est au début à la dose moyenne de 107 (56) μg puis à la fin de la première année de 61 (46) μg (p <0,0001). La dose de F.IV, injecté une fois par semaine l’est à la dose de 87 (23) mg puis de 57 (40) par injection (p <0,001). Parmi ces 102 patients, 33 ont reçu au cours de la prédialyse, du F.IV. Ces patients, par rapport aux autres, abordent la dialyse avec un meilleur taux d’Hb : 11,1 (1,3) versus 10,4 (1,5) (p <0,01), ont un coefficient de saturation de la transferrine (CST) à 50,0 (19,2) % versus 30,1 (15,2) (p <0,001), reçoivent moins de DA 0,58 (0,28) μg/kg par semaine versus 0,82 (0,37) (p <0,001). Les faits les plus marquants concernent les données cardiovasculaires : index de masse ventriculaire gauche (MVGi), à 116 (34) g/m2 versus 134 (39) g/m2 (p <0,02), fraction d’éjection du ventricule gauche (FEVG) à 64,7 (4,4) % versus 61,4 (8,7) % (p <0,02) et pression artérielle moyenne (PAM) plus basse à 104,7 (8,0) mmHg versus 109,5 (13,2) mmHg (p <0,02). Enfin, ces patients sont moins hospitalisés au cours de la première année. Ainsi, la meilleure prise en charge de l’anémie en prédialyse par du F.IV et ASE transforme les paramètres de l’anémie et les données cardiovasculaires de ces patients au cours de la première année de dialyse. [Copyright &y& Elsevier]

Patients andmethod: An observational study was carried out in an oncology department that had initiated an active anaemia management strategy using ESA (darbepoetin-alpha) in order to observe the resulting changes seen in the use of transfusions and to assess the effectiveness of this strategy in controlling anaemia in clinical practice. Data were gathered from medical files of all patients treated with ESA for anaemia during two successive periods of a year. The first period corresponded to the implementation of this strategy within the unit (from September 2006), and the second period (from April 2008) could be regarded as a phase of stable practice. Results: The percentage of patients treated with ESA increased slightly, from 23.3 to 26.8%, for the active group, which remained almost identical during the two periods (897-899 patients). The average number of ESA injections per patient decreased (3.21 compared to 2.88, NS). The number of transfusions reduced by about 19% across the two periods. Analysis of the effectiveness of treatment was carried out on a cumulative number of 339 patients, who received a continuous sequence of ESA injections during the same course of chemotherapy, with at least three injections of ESA. This corresponded to 205 patients in period one and 134 patients in period two. Effectiveness was defined as a function of the changes in Hb level (ΔHb) in three categories: 39.8% of patients were judged to have responded well (ΔHb ≥ 1 g/dl), 36.9% as having had an intermediate response (0 ≤ δHb < 1 g/dl) and if ΔHb < 0, they were classified as not responded (33.3%). Improvements in Hb levels during successive ESA injections were more significant for patients presenting with initially low Hb levels. Conclusions: The results obtained show that the effectiveness of darbepoetin-alpha observed in clinical practice is in agreement with that demonstrated in clinical trials, and confirms that treatment with darbepoetin-alpha substantially decreases the need for transfusions. [ABSTRACT FROM AUTHOR]

Copyright of Néphrologie & Thérapeutique is the property of John Libbey Eurotext Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Néphrologie & Thérapeutique is the property of John Libbey Eurotext Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Néphrologie & Thérapeutique is the property of John Libbey Eurotext Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Various studies highlight cognitive impairments in cancer patients. This paper proposes a review of longitudinal controlled studies evaluating the efficacy of interventions aiming to reduce these cognitive impairments. Longitudinal controlled studies evaluating the efficacy of interventions aiming to reduce cognitive impairments in adult cancer patients and published between 1993 and 2013 were identified, with the exception of studies that implied patients suffering from CNS tumor or metastasis. Pharmacological interventions (n = 11) suggested the positive impact of modafinil on memory and executive functions. Non-pharmacological interventions (n = 10) suggested the positive impact of cognitive revalidation and stimulation programs, psycho-education and meditation on several memory, attentional and executive objective as well as subjective functions. Non-pharmacological interventions show more significant cognitive benefits than pharmacological interventions. Some longitudinal controlled studies support the usefulness of interventions aiming to reduce cognitive impairments in cancer patients. Further studies should evaluate the effectiveness of programs combining technics aiming to reduce cognitive impairments and psychotherapeutic technics aiming to support patients' coping with illness.

Individualized use of iron therapy (IT) and erythropoiesis-stimulating agents (ESA) may effectively correct anemia and its symptoms in CKD patients (Pts). The aim of this retrospective study was to precise the anemia management (AM) in incident HD Pts, and to compare Pts treated by intravenous (i.v.) IT and ESA during predialysis to those treated by oral IT and ESA on AM and cardiovascular parameters during the first year of HD. One hundred and two Pts performed their first dialysis in the unit, mean age 58.5 (15.9) years, 70% males, 27% diabetes. Ninety Pts started with a native arteriovenous fistula. Charlson comorbidity index was 7.3 (3.5). Mortality rate was 3% at one year. Hb level was at start 10.6 (1.7) and at one year 11.7 (1.1) g/dL (P<0.0001). DA injected every 2weeks was at the beginning at 107 (56) μg and then at 61 (46) (P<0.0001). i.v. IT injected every week was at the dosage of 87 (23) mg and then at 57 (40mg) per injection (P<0.001). Out of 102 Pts, 33 received i.v. IT during predialysis. These Pts started dialysis with a better Hb level: 11.1 (1.3) versus 10.4 (1.55) g/dL (P<0.01), had a TSAT at 50.0 (19.2) versus 30.1 (15.2) % (P<0.001), received less ESA 0.58 (0.28) versus 0.82 (0.37) μg/kg per week (P<0.01). More important were the changes on the cardiovascular functions: left ventricular mass at 116 (34) versus 134 (39) g/m(2) (P<0.02), left ventricular ejection fraction at 64.7 (4.4) versus 61.4 (8.7) % (P<0.02) and mean arterial pressure at 104.7 (80) versus 109 (13.2) mmHg (P<0.02). These Pts were also less hospitalized. This study revealed the importance of i.v. IT during predialysis care not only on AM but also on cardiovascular status in HD Pts starting dialysis., (Copyright © 2013 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.)

Darbepoetin alfa is a recombinant erythropoiesis-stimulating agent, with a longer half-life leaving the possibility to extending dosing administration in haemodialysis patients. A protocol of injection every 2weeks was initiated in the dialysis unit. From 2005 to 2007, 176 dialysis patients were studied with a target haemoglobin level between 11 and 12.5g/dL: the median haemoglobin level was ranged from 11.32 and 11.72g/dL during the study with a median darbepoetin alfa dose injected between 60 and 64μg per injection (0.46 to 0.47μg/kg per week). The mean number of dose changes was three per year per patient. The diabetic population did not differ from the general population in terms of haemoglobin levels and doses of darbepoetin alfa. Ten percent of the patients had to resume one injection per week for medical reasons: the profile of these patients was carefully studied. Hospitalisations resulted in a decrease in haemoglobin level and an increase in the darbepoetin alfa doses. Patients who died showed during the last 3months, a particular profile. Hyporesponsiveness has been explored. Time saving with this protocol was important for all the nursing staff. Although numerous factors of variability have been studied, there still a room for improvement of anemia management in haemodialysis patient., (Copyright © 2011 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.)

Introduction: Management of anaemia in chronic renal insufficiency (CRI) represents an important medico-economic challenge because of the great number of patients and the cost of the erythropoiesis-stimulating agent (ESA). The aim of this study was to identify determinants of the costs associated with these treatments in order to choose, with equal efficacy, the most efficient ASE., Method: A bibliographic research was realised by Medline database interrogation., Results: Among the direct medical costs, five studies showed that acquisition of epoetine alfa (EA) compared to darbepoetin alfa (DA) was less expensive. Concerning the costs associated with the route of administration, the subcutaneous injection (SC) of epoetine allowed a gain in costs because of the decrease of doses compared to the intravenous (IV) route. The switch from EA in SC to DA in IV, for hemodialysis patients, was associated with a reduction of the number of injections and with a treatment's cost lower by DA than by EA. Costs related to the regimen of administration, notably those related to nursing, medical and pharmaceutical time, were negligible towards those associated to the acquisition of the ASE. Finally, the costs of the therapeutic follow-up and treatment of the adverse effects of the ASE were similar between the EA and the DA., Conclusion: The costs associated with the prices of acquisition of the ASE, negotiated by the structure of care, represent the most important part of the direct medical costs., (Copyright 2009 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.)

Darbepoetin alfa is an erythropoeisis-stimulating agent that can be given in an every week (QW) or every-3-weeks (Q3W) schedule for the treatment of chemotherapy-induced anemia. We assessed the cost-effectiveness of Q3W darbepoetin alfa compared to QW darbepoetin alfa, from both a health-care and societal perspective in France. Based on a clinical trial design, a decision-tree model with a 16-week time horizon was developed in Excel(R). A probabilistic sensitivity analysis was carried out. The Q3W regimen resulted in lower total costs per patient from the health-care (-180 euro [95 % CI = -461.2;74]) and societal (-243 euro [95 % CI = -588;62]) perspective. Probabilistic sensitivity analysis showed an incremental cost-effectiveness ratio in favor of Q3W treatment from both perspectives. The Q3W schedule is cost saving compare to the QW schedule. It also reduces the burden of the frequent visits for the patients.

Unlabelled: Beginning 1998, a working group of specialists convened by the guidelines department (Standards, Options and Recommendations: SOR) of the National French Federation of Comprehensive Cancer Centres (FNCLCC) published then regularly updated Recommendations relative to the use of ESA in anaemic patients with cancer. This article presents a short version of the Recommendations updated in 2007., Methods: This updating process is based on the methodology developed and used in the "Standards, Options: Recommendations" programme. The methodological approach combines systematic review with the judgement of a multidisciplinary group of experts. A Recommendation is a proposal of one or several clinical attitudes intended to improve cancer patient care. There are two levels of gradation for the Recommendations: Standards and Options. Their setting takes into account the organisational context of care, the particular situation of the patient and the expression of his preferences. Before publication, the RPC-SOR are re-examined by independent reviewers selected according to the same principles as the group of expert writers., Results: New data are sufficiently important to update the latest Recommendations validated in 2003. Thus, five clinical questions were updated. The resulting modifications were either major (new Options or new Standards) or minor (increased level of evidence). It should be noted that for the clinical question--use of ESA in radiotherapy--new data are not sufficient to generate modifications in the initial Recommendations which remain valid., Conclusions: Because of the important new data published on the subject between 2003 and 2007, it appears relevant to re-examine these Recommendations according to a systematic monitoring process which should be renewed in 2 years.

Although anemia is a common complication of chronic kidney disease, practice variability in its management continues to exist. In an effort to standardize management, the Northern Alberta Renal Program implemented an anemia algorithm, the "Anemia Protocol." A cohort design was used to evaluate the effectiveness of the "Anemia Protocol" in 98 patients three months pre-implementation and three and six months post- implementation. Clinical outcomes of hemoglobin levels, iron indices, erythropoietin and iron dosages, and its associated costs, were compared pre- and post-implementation of the algorithm. This study did not show significant change in anemia or anemia management pre- versus post-implementation of the "Anemia Protocol" in the Northern Alberta Renal Program. However, this is not to imply that algorithms are not useful in clinical settings. Anemia algorithms are invaluable in standardizing management and limiting practice variability, but to ensure that intended clinical outcomes are achieved, algorithms need to be regularly evaluated and revised as necessary.

Correcting the renal anemia in dialysis patient require the optimal management of the erythropoietic stimulating agents (ESA) available on the market. In other words, that means that the prescription of these agents should be performed according to the specific pharmacokinetic and pharmacodynamic profiles of these agents. Two major classes of ESA are presently available for clinicians: one being considered as short acting substances (epoetine alfa and Epoetine Beta); the other one being considered as long acting substances (darbepoetin alfa). Several other agents are being currently evaluated or waiting for approval. For the short acting ESA, subcutaneous administration has been proved able to reduce weekly needs by 20 to 30% for the same efficacy, while the optimal frequency dosing being once and twice per week. For long acting ESA, the beneficial effect of the subcutaneous administration tend to disappear in hemodialysis patient, while the optimal frequency dosing being once a week to once every two week. These treatment schedules of prescription must be adapted according to the dialysis modality (hemodialysis, peritoneal dialysis) and the basal needs for ESA. The efficiency of ESA is also conditioned by the dialysis quality and efficiency, the iron repletion state, the blood losses and the presence of resistance factors. The optimal management of anemia in dialysis patient relies on an optimized dosing of ESA, a reduction of blood losses and a suppression of resistance factors to ESA action.

Darbepoetin alfa is a unique genetically engineered glycoprotein with a three-fold longer terminal half-life than recombinant human erythropoietin (rHuEPO). The objective of this study was to determine if darbepoetin alfa administered at a reduced dosing frequency relative to the prior rHuEpo regimen is an effective and safe alternative for treating renal anemia in patients undergoing dialysis. A total of 1,008 French hemodialysis and peritoneal dialysis patients receiving stable rHuEPO therapy by either the intravenous (i.v., N = 217) or subcutaneous (s.c., N = 791) route were switched to darbepoetin alfa given by the same route of administration at a reduced dosing frequency. Patients receiving rHuEPO once weekly (N = 248, 25%) were switched to darbepoetin alfa every two weeks, and those receiving rHuEPO two or three times weekly (N = 760, 75%) were switched to darbepoetin alfa once weekly. The doses of darbepoetin alfa were titrated to maintain hemoglobin concentration in the target range of 10.0 to 13.0 g/dl for up to 24 weeks. The primary endpoint was the change in hemoglobin between baseline and the evaluation period (weeks 21-24). Adjusted (for covariates that might influence hemoglobin response) mean change in hemoglobin from baseline to the evaluation period was not clinically significant: +0.11 g/dl (95% CI: -0.30; 0.52). An i.v./s.c. dose ratio of 0.96 (95% CI: 0.86; 1.06) at evaluation confirms previous findings that darbepoetin alfa dose requirements were not different for the s.c. and i.v. routes. At the end of the evaluation period, more than 98% of patients successfully maintained hemoglobin within the target range and at their darbepoetin alfa assigned dosing frequency. Darbepoetin alfa was well tolerated with a safety profile consistent with that observed in previous darbepoetin alfa studies. Darbepoetin alfa administered at a reduced dosing frequency relative to the prior rHuEpo regimen effectively maintains hemoglobin in the target range in dialysis patients with renal anemia.

The Standards, Options and Recommendations on the use of erythropoietin in cancer patients are recalled. The recent literature is analysed and allows some further comments to the SOR. Medico-economic aspects, new schedules of administration, extra-hematologic virtues of erythropoietin and its impact on cancer outcomes are debated.

Febrile neutropenia and anemia are two major complications of chemotherapy. Human recombinant cytokines as G-CSF and erythropoietin allow efficient fight against these secondary effects but require iterative injections due to a short half life. The glycosylation of natural cytokines results in enhanced stability of these molecules of new generation and makes it possible to space the injections which become concomitant of chemotherapies. With regard to the erythropoietin, the prolonged half-life form shows a similar effectiveness with the natural molecule. For the G-CSF, the glycosylated form could still show itself more effective for the prevention of febrile neutropenias. Finally, these new molecules allow an improvement of the quality of life while ensuring an optimal dose-intensity of the treatment.