Intravenous and subcutaneous Epoetin administration in the maintenance of optimal haemoglobin levels in end-stage renal failure patients on haemodialysis

Abstract

Overview of the Topic: Maintaining optimal Haemoglobin (Hgb) levels amongst end stage renal disease (ESRD) patients remains a day to day challenge for health care professionals practising in renal units. Locally, subcutaneous (SC) Epoetin is administered to treat and prevent possible renal anaemia. Maintaining optimal Hgb levels amongst ESRD patients is crucial as renal anaemia can result in rapid deterioration due to various co-morbid conditions that can arise. This literature review aimed to understand the effect of intravenous (IV) route when compared to SC administration of Epo in relation to maintenance of optimal Hgb. Research Question: Based on the Population Intervention Comparison Outcome (PICO) framework the following research question was formulated: 'In adults with end-stage renal failure on haemodialysis (P), is intravenous Epoetin (I) more effective than subcutaneous Epoetin (C) in maintaining optimal haemoglobin levels (O)?' Search Strategy: Different databases and search engines were systematically searched to retrieve relevant literature, including Hy-Di, EBSCO, PubMed, PubMed MeSH and also Google Scholar. Different keywords were generated to obtain relevant literature and these included EPO, Epoetin, Human recombinant erythropoietin, erythropoietin administration*, Subcutaneous, Intravenous, Haemoglobin, H$emoglobin level/response or concentration and Renal anaemia. Studies conducted amongst paediatrics, not using English language, showing mediocre methodology which is not regarded in the hierarchy of evidence and also showing different outcomes were excluded. After applying these inclusion and exclusion criteria, eight articles were identified for further appraisal. These consisted of one Meta-analysis (MA), five Randomised Controlled Trials with cross-over designs and two cohort studies. These studies were appraised by means of the Critical Appraisal Skills Programme (CASP) tools for Systematic reviews, Randomised control studies and Cohort studies respectively. Results: The eight studies being appraised yielded different results. Five studies consisting of one MA, two RCTs and two cohort studies showed that SC administration was significantly better than IV administration in maintaining Hgb levels within normal levels with a significantly lower dose. On the other hand only three RCTs have showed no significance between routes in relation to maintenance of optimal Hgb levels. Conclusion: In conclusion, the majority of the studies (n=5) have shown that a higher dose of IV Epoetin was required to maintain target Hgb levels when compared to SC Epoetin. Recommendations: Although the majority of studies have shown that SC mode of administration of Epoetin showed better Hgb levels with lesser dose, these have urged for further research with larger populations. Locally, future research would assist professionals to obtain possible improvement amongst present practices and protocols. In order to improve present clinical practices, efforts towards introducing better understating of this issue by means of latest and updated knowledge to all professionals involved must be provided.