[How to best use ESA in dialyse patients? What are the criterions of choice? What is the role of the age, the nephropathy and the dialysis modality? What are the current recommendations?].

Correcting the renal anemia in dialysis patient require the optimal management of the erythropoietic stimulating agents (ESA) available on the market. In other words, that means that the prescription of these agents should be performed according to the specific pharmacokinetic and pharmacodynamic profiles of these agents. Two major classes of ESA are presently available for clinicians: one being considered as short acting substances (epoetine alfa and Epoetine Beta); the other one being considered as long acting substances (darbepoetin alfa). Several other agents are being currently evaluated or waiting for approval. For the short acting ESA, subcutaneous administration has been proved able to reduce weekly needs by 20 to 30% for the same efficacy, while the optimal frequency dosing being once and twice per week. For long acting ESA, the beneficial effect of the subcutaneous administration tend to disappear in hemodialysis patient, while the optimal frequency dosing being once a week to once every two week. These treatment schedules of prescription must be adapted according to the dialysis modality (hemodialysis, peritoneal dialysis) and the basal needs for ESA. The efficiency of ESA is also conditioned by the dialysis quality and efficiency, the iron repletion state, the blood losses and the presence of resistance factors. The optimal management of anemia in dialysis patient relies on an optimized dosing of ESA, a reduction of blood losses and a suppression of resistance factors to ESA action.