Erythropoiesis-stimulating agents increase the risk of acute stroke in patients with chronic kidney disease

Stephen L. Seliger, Amy D. Zhang, Matthew R. Weir, Loreen Walker, Van Doren Hsu, Afshin Parsa, Clarissa J. Diamantidis, Jeffrey C. Fink

Research output: Contribution to journalArticlepeer-review

40 Scopus citations


Erythropoiesis-stimulating agents (ESAs) are effective in ameliorating anemia in chronic kidney disease (CKD). A recent trial in diabetic patients with CKD, however, suggested a greater risk of stroke associated with full correction of anemia with ESAs. Using national Veterans Affairs data we performed a case-control study examining the association of incident ESA use with acute stroke in patients with estimated glomerular filtration rate 60 cm 3/min per 1.73 m 2 and outpatient hemoglobin 12 g/dl. Using diagnosis codes, we identified 2071 acute hospitalized stroke cases and matched them 1:5 with controls without stroke, resulting in 12,426 total patients for analysis. Conditional logistic regression was used to estimate the association of ESA use with stroke, adjusting for potential confounders. After multivariate adjustment, ESA use in 1026 patients was associated with greater odds of stroke (odds ratio 1.30). There was significant interaction between ESA use and cancer, with greater odds of stroke among ESA-treated cancer patients (odds ratio 1.85), but not in ESA-treated patients without cancer (odds ratio 1.07). ESA-treated patients with cancer received a median initial dose 2.5-4 times greater than ESA-treated patients without cancer, but pre-ESA hemoglobin and its rate of change did not differ between these groups. Hence, in a large national sample of anemic patients with CKD, ESA treatment was associated with an increased risk of acute stroke with the greatest effect among patients with cancer.

Original languageEnglish (US)
Pages (from-to)288-294
Number of pages7
JournalKidney international
Issue number3
StatePublished - Aug 1 2011
Externally publishedYes


  • cardiovascular events
  • chronic kidney disease
  • epidemiology and outcomes
  • epoetin

ASJC Scopus subject areas

  • Nephrology


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