# Effect of erythropoiesis-stimulating agent types on malignancy in hemodialysis patients

## TL;DR

This study finds that long-acting erythropoiesis-stimulating agents may increase cancer risk in hemodialysis patients, especially those on higher doses.

## Contribution

The study is the first to show a link between long-acting erythropoiesis-stimulating agents and increased malignancy risk in hemodialysis patients.

## Key findings

- Long-acting ESA users had a higher malignancy risk compared to short- and intermediate-acting ESA users.
- Higher malignancy risk was observed in males, older individuals, and those on higher ESA doses.
- Survival rates were not affected by the type of ESA used.

## Abstract

Since erythropoiesis-stimulating agent (ESA) types vary in their affinity for receptors, investigating their association with malignancies could offer valuable insights. This study aims to evaluate the effect of ESA types on malignancy incidence in hemodialysis (HD) patients.

The Health Insurance Review and Assessment Service has operated a nationwide HD quality assessment program to address the high medical costs and mortality rates among HD patients. This retrospective study analyzed data from 33 960 HD patients, who underwent fourth and fifth HD quality assessments. Participants were divided into three groups: short-, intermediate- and long-acting groups. The onset of any malignancy was defined as the date of the first diagnosis based on International Classification of Diseases, Tenth Revision codes for the 12 most common malignancies. Patient survival was assessed for those with a first diagnosis of any malignancy during follow-up.

The short-, intermediate- and long-acting groups comprised 26 006, 6448 and 1506 patients, respectively (over ∼75 months of follow-up). The 5-year malignancy-free rates were 88.4%, 88.2% and 87.0% for short-, intermediate- and long-acting groups, respectively (P = .024 for short/intermediate-acting vs long-acting group). Univariable and multivariable analyses showed higher malignancy risk in the long-acting group, especially in males, older individuals and those on higher ESA doses. We performed analyses using a balanced cohort after propensity score weighting. The balanced cohort also confirmed higher malignancy risk in the long-acting group, while survival rates remained unaffected by ESA type.

Our population-based cohort study reveals an association between long-acting ESAs use and the incidence of any malignancy, with a particularly strong influence on high-dose users. This suggests that avoiding long-acting ESAs may be advisable for patients at high risk of malignancy.