Do you avoid ESAs in patients with end stage kidney disease who also have heart failure due to increased risk of stroke?

If the question is whether I avoid ESAs in patients with ESKD who also have heart failure, the answer is no for several reasons. The warning in the ESA package insert regarding using ESAs with caution in patients with heart failure (HF) comes from the CHOIR study (Singh, et al., PMID 17108343) of non-dialysis dependent (NDD) CKD patients comparing a target Hb level of 13.5 with one of 11.3 g/dL. The patients in the higher target Hb arm had a higher incidence of the composite safety outcome including hospitalization for HF, but we don't target Hb levels >11.5 anymore for this reason. The TREAT study (Pfeffer et al., PMID 19880844) of type 2 diabetic NDD-CKD patients compared target Hb of 13.0 with a placebo-treated group who received ESA onl...

I don’t. I think if used wisely, the thrombotic risk of ESA’s is low. Furthermore, the improvement in hemoglobin would help these patients tremendously.