By a mistake of communication I was scheduled to give the anemia talk at a recent chronic kidney disease symposium. I would have never selected this topic on my own. I work with Robert Provenzano, one of the Gods of Anemia. Fortunately, this was a happy accident. I loved researching and writing this presentation. The whole experience was an important lesson on the value of working out of your comfort areas.
The anemia saga is well known to all nephrologists and is covered in depth in my presentation but let me recap my version of the story.
Life before Epo was pretty bad. the average dialysis patient received a transfusion more years than not. On the Eve of Epo the transfusion was rate was 16% per quarter!
|I tried to find Henry Paulson’s signature but had to settle for George Bush’s.|
|8 Epo vs Epo studies and 3 placebo controlled trials, 1 placebo controlled trials in pediatrics|
|Favorite slide from the deck|
Reading this editorial by Marc Pfeffer crystalized this critical mistake. I spent a fair proportion of the presentation laying out how statins evolved from being used in only the sickest patients to larger and larger populations and how at each step placebo controlled trials were used to prove efficacy. Not every step was a win, statins for heart failure failed, but the key is that cardiologists know that statins don’t improve heart failure because they tested it with two (1, 2) placebo-controlled trials.
Why is nephrology lacking the randomized controlled trials that have defined the huge advancement in cardiovascular disease over the last 25 years?
- It isn’t due to the severity of illness, the first placebo controlled trial of ACEi in heart failure used a cohort with 40% mortality at 6 months.
- It isn’t timing, ACEi for heart failure was developed and proven at the same time as the introduction of Epo.