貧血的原因在上一篇已經有大致說明,不外乎主要三個大原因:“生的少、死的早、鐵嘸夠”,這篇我們針對“生的少”來討論要如何改善。
腎臟病到了後期,腎臟功能指數(eGFR)剩下30-60分左右時,患者發生貧血的比例逐漸增加,主要是因為腎臟所製造的紅血球生成素(Erythropoietin,簡稱EPO),產量逐漸下降。
既然體內的量不夠,那就從體外來補充吧!美國FDA於1989年起,核准合成的“刺激紅血球生長素(Erythropoiesis-stimulating agent,簡稱ESA)”可以使用在人體上,至今也已經20多年了。經過這些年的研發,目前經常使用的ESA有三種,依照效果持續的時間長短排列如下:
Epoetin alfa 或 beta (rHuEpo)
第一代的產品,看那簡稱的結尾也是EPO,這就是說它的結構,與人體內腎臟所製造的紅血球生成素幾乎一樣,作用時間最短,如果要獲得比較好的效果,一個星期需要打三次,皮下注射效果比靜脈注射好。
Darbepoetin alfa (DPO)
第二代產品,利用分子結構的改變,使得作用時間是前一代的三倍,也就是說一個星期只需要打一次,根據研究,靜脈注射與皮下注射的效果差不多,所使用的劑量也無多大差別。
Methoxy polyethylene glycol-epoetin beta (PEG-EPO,或稱CERA)
第三代產品,分子結構改變的更多了,因此作用時間最久,一個月只要打一次,價格也最貴,較常使用於腹膜透析患者。
有被上面這一堆縮寫搞混了嗎? 讓我再統整一次吧,EPO是人體自己製造的荷爾蒙,ESA是具有相同效果的合成藥物,而 rHuEpo、 DPO、 CERA這三種藥物都是 ESA的其中之一,主要差別在於作用時間長短。如果你能看的懂以下的句子,那就真的懂了:
因為洗腎患者的體內 EPO不夠,所以需要補充 ESA,血液透析患者常使用的ESA是 rHuEPO或者 DPO,腹膜透析患者常使用的 ESA是 CERA。
血色素應該要多少以上才算夠呢?
根據2012年美國KDIGO治療指引所述,使用ESA的目標是避免血色素低於 9 g/dL,所以當血色素低於10 g/dL的時候,應該開始使用ESA。而2013年美國KDOQI針對KDIGO之評論指出,洗腎患者的血色素(hemoglobulin,Hb) 應該維持在 9-11 g/dL之間,當超過 11 g/dL時,應該停止使用ESA。
ESA並非毫無疑慮
有研究報導顯示,如果患者之前罹患過癌症,使用ESA有增加癌症死亡的趨勢;此外,使用ESA也會增加中風的危險性,尤其是之前就有中風病史的患者。
不過,在上述的兩個治療指引中,只加上了警語“需小心使用”,並沒有禁止使用,這表示證據仍然薄弱。然而,這也是給大家一個警惕,補血針(ESA)不能無限制的一直打,若達到血色素的目標值,就該減量或停止使用,這樣才能減少使用藥物的風險。
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