Is there a role for adjuvant therapy in patients being treated with epoetin

form of adjuvant therapy; intravenous (i.v.) iron is cytokines; iron; vitamins required by the majority of haemodialysis patients receiving epoetin. Measurement of hypochromic red blood cells is the most direct way of assessing iron supply to the bone marrow. During the correction Introduction phase, a dose of i.v. iron equivalent to 50 mg/day is recommended, with the total dose not exceeding 3 g. The potential role of adjuvant therapies in enhancing When subclinical vitamin C deficiency is suspected, the eVectiveness of epoetin in chronic renal failure ascorbic acid may be given orally (1‐1.5 g/week) or (CRF ) patients has received increasing attention in i.v. (300 mg three times weekly at the end of dialysis). recent years. Adjuvant therapies are important for two The active vitamin D metabolites alfacalcidol and reasons. Firstly, they may help to overcome hypocalcitriol may, under some circumstances, improve responsiveness to epoetin, allowing patients to achieve anaemia and reduce epoetin dosage requirements. increased haemoglobin concentrations and derive Vitamin B 6 requirements are increased during epoetin greater clinical benefits. Secondly, they may allow therapy, and supplementation at a dose of 100‐ epoetin to be used more cost-eVectively. 150 mg/week is recommended. Supplementation of When haemoglobin does not increase as much as vitamin B 12 is optional. Folic acid is supplemented expected in response to epoetin treatment, the presence routinely in haemodialysis patients, though evidence of either a correctable underlying disorder (such as that it increases the eYcacy of epoetin is limited. Low infection or inflammation) or a deficiency state that doses (2‐3 mg/week) should normally be suYcient to could be limiting erythropoiesis must be considered. maintain optimal folic acid stores in epoetin-treated In the last few years, it has become apparent that iron patients, although higher doses are necessary for deficiency is the major cause of hyporesponsiveness to patients with hyperhomocysteinaemia. l-Carnitine epoetin, and most institutions are now fully aware that supplementation may be appropriate in some patients the majority of haemodialysis patients receiving epoetin with anaemia of chronic renal failure (CRF ) unre- will also need intravenous (i.v.) iron supplementation. sponsive to, or requiring large doses of, epoetin. Attention has recently turned towards the usefulness Androgens potentially could reduce epoetin costs in of other adjuvant therapies, including vitamins, horcountries with limited resources, but should only be mones and cytokines. Nutritional status has always used in men older than 50 years with a remnant kidney. been of concern in patients with CRF; now there is Recent animal studies indicate that the combination increasing awareness that deficiency states may underof epoetin and insulin-like growth factor 1 might be mine the eVectiveness of epoetin. Although nutritional beneficial in CRF patients. High doses of angiotensin- supplementation has long been routine practice for converting enzyme (ACE) inhibitors should be patients with CRF, recent research highlights the reserved for dialysis patients who have hypertension specific roles that some vitamins and l-carnitine may