Erythropoiesis-Stimulating Agents and Development of Cancer Among Patients Receiving Dialysis

Abstract

This case-control study evaluates the association between treatment with erythropoiesis-stimulating agents and cancer risk in patients receiving long-term dialysis. QuestionIs there an association between erythropoiesis-stimulating agents (ESAs) in the management of anemia and cancer risk in patients with kidney failure?FindingsIn this case-control study of 9776 patients undergoing dialysis, high-dose ESA use was associated with higher odds of new cancer development among older patients (aged >= 60 years).MeaningThese findings suggest caution should be exercised to avoid aiming for excessively high hemoglobin levels during ESA therapy. ImportanceAlthough erythropoiesis-stimulating agents (ESAs) are widely used to treat anemia in patients with kidney failure, concerns have been raised about their potential to promote tumor growth. However, the association between ESA use and incidence of cancer in patients undergoing long-term dialysis remains unclear.ObjectiveTo examine the association between ESA use and cancer development among patients receiving long-term dialysis.Design, Setting, and ParticipantsThis nested case-control study identified patients in the Korean National Health Insurance Service database with kidney failure who began long-term dialysis treatment and received ESAs between 2006 and 2017 in Korea. Each case with incident cancer was matched with 4 controls based on age, sex, follow-up time, year of dialysis initiation, and dialysis modality. Data were analyzed between August 2024 and August 2025.ExposureESA exposure was categorized as high or low dose according to the median of the mean weekly dose of each ESA drug.Main Outcomes and MeasuresThe primary outcome was newly diagnosed cancer occurring 6 months after the initiation of long-term dialysis. Conditional logistic regression, adjusted for potential confounders, was used to assess the association between ESA use and cancer development.ResultsA total of 9776 patients (mean [SD] age, 62.2 [12.0] years; 6296 [64.4%] male) undergoing dialysis were included; 2320 patients with incident cancer were matched to 7456 controls. After multivariable adjustment, high-dose ESA use was found to be associated with increased odds of cancer development (adjusted odds ratio, 1.23; 95% CI, 1.11-1.35) compared with low-dose use. Stratified by age, the odds of cancer development were 0.90 (95% CI, 0.77-1.05) among patients aged younger than 60 years and 1.47 (95% CI, 1.30-1.67) among those aged 60 years or older.Conclusions and RelevanceIn this case-control study of patients undergoing dialysis, high-dose ESA use was associated with greater odds of new cancer development. These results suggest that caution should be exercised to avoid aiming for excessively high hemoglobin levels during ESA therapy.