# Excessive Ultrafiltration Associates with EPO Hyporesponsiveness in Elderly Chronic Hemodialysis Patients

## TL;DR

High ultrafiltration rates in elderly hemodialysis patients may worsen anemia treatment needs, especially when iron levels are low.

## Contribution

This study identifies a link between excessive ultrafiltration and increased erythropoietin resistance in elderly hemodialysis patients.

## Key findings

- Patients with higher ultrafiltration rates required higher ESA doses despite similar hemoglobin levels.
- Lower hepcidin levels were observed in high ultrafiltration patients with low transferrin saturation.
- Ultrafiltration appears to impact ESA response, particularly in patients with limited iron availability.

## Abstract

Background: The population of elderly patients undergoing chronic hemodialysis is increasing, and anemia represents a frequent complication. The aim of our study was to evaluate the association between ultrafiltration rate (UFR) in hemodialysis and erythropoietin (EPO) response in elderly patients with end-stage kidney disease (ESKD). Methods: This was a multicenter, retrospective observational study, involving elderly patients (aged 65 years or more) under chronic hemodialysis therapy. Individuals were divided into two groups according to the UFR adjusted to weight (UFR/W): lower (UFR-N) or higher (UFR-H) than 10 mL/h/kg. EPO resistance index (ERI) was calculated. We evaluated the hemogram, reticulocyte count, and quantified markers of iron metabolism and inflammation. Results: A total of 193 patients were enrolled in the study: 141 patients met criteria for inclusion in UFR-N group and 52 in UFR-H group. Compared to UFR-N, patients in the UFR-H group presented significantly higher doses of erythropoiesis-stimulating agents (ESA) and ERI values, with similar hemoglobin (Hb) and inflammatory markers levels. In a sub-analysis, within patients presenting transferrin saturation (TSAT) lower than 20%, a more marked difference in ERI between UFR groups was observed, being much higher in UFR-H compared with UFR-N. In this subgroup (UFR-H with lower TSAT), levels of hepcidin were lower than in the other subgroups. Conclusions: Our data show that UFR appears to be a contributing factor of ESA response in elderly patients under hemodialysis, particularly in those with lower iron availability. These findings suggest that inadequate weight control and/or UF prescription seem to aggravate ESA needs to achieve target Hb.