Erythropoiesis-stimulating agents and cardiovascular mortality: A systematic review and meta-analysis of 17 studies and 372,156 hemodialysis patients

INTRODUCTION: Prior studies on the association between erythropoiesis-stimulating agents (ESAs) and cardiovascular mortality in hemodialysis patients have yielded conflicting findings. We aimed to clarify this relationship through a systematic review and meta-analysis of current evidence. METHODS: We comprehensively searched major databases for observational and interventional studies on ESA use and cardiovascular mortality in hemodialysis patients published from 1980 to September 2023. Pooled risk ratios (RR) with 95 % confidence intervals (CI) were calculated using random-effects models. Sources of heterogeneity were explored through subgroup analyses and meta-regression. The study data were analyzed using Stata 15 software. FINDINGS: Upon conducting the initial search, we extracted 792 articles and, after screening and considering the research criteria, 17 studies with 372,156 participants were included in the meta-analysis. Overall, ESA use was associated with a 27 % increased risk of cardiovascular mortality (RR 1.27, 95 % CI: 1.15–1.40, p < 0.001). This risk varied by geographical location, with RRs of 1.27 (95 % CI: 1.14–1.41; p-value≤0.001) for America, 1.33 (95 % CI: 1.12–1.58; p-value = 0.001) for Asia, and 1.23 (95 % CI: 1.02–1.49; p-value = 0.028) for Europe. Importantly, a gender disparity was revealed, with studies involving a higher proportion of males showing greater risks (RR 1.51, 95 % CI: 1.25–1.83, p < 0.001) than female-predominant studies (RR 1.08, 95 % CI: 0.86–1.36, p < 0.001). CONCLUSION: Our meta-analysis indicates ESA use is associated with heightened cardiovascular mortality in hemodialysis patients, especially in males. These findings have implications for optimizing dosing strategies while balancing efficacy and safety. Further research is warranted, particularly randomized controlled trials, to establish definitive ESA dosing guidelines.