*Purpose: Post-transplant anemia (PTA) is a common phenomenon in renal transplant recipients (RTR). There are currently no consensus guidelines for PTA, however patients are commonly treated with erythropoiesis-stimulating agents such as darbepoetin alfa (DA). While previous studies have shown the efficacy of DA in RTR with PTA, optimal dosing remains controversial. The purpose of this study is to evaluate two dosing strategies for DA in RTR with PTA.

*Methods: This retrospective cohort study was conducted in RTR who received at least one dose of DA from September 2019 to August 2021 at Baylor All Saints in Fort Worth and January 2021 to August 2021 at Baylor University Medical Center in Dallas. Patients were stratified into 2 groups: high fixed-dose (HFD) of 200 mcg or weight-based dose (WBD) of 0.45 mcg/kg. Primary outcome was a composite of hemoglobin (Hgb) > 10 g/dL and freedom from blood transfusion by 12 weeks post DA initiation. Secondary outcomes include the median dose of DA, median number of DA doses per patient, change in baseline Hgb, and GFR estimated by the six variable Modification of Diet in Renal Disease (MDRD6) equation at 12 weeks. Safety outcomes include the incidence of myocardial infarction, stroke, venous thromboembolism (VTE), and mortality.

*Results: Of the 110 patients that received at least one dose of DA, 49 (45%) received WBD and 61 (55%) received HFD. Baseline characteristics were similar between groups except for more Alemtuzumab use in HFD and rabbit anti-thymocyte globulin in the WBD group (Table 1). The WBD group had a significantly higher incidence of the primary composite outcome compared to the HFD group (61.2% vs 41%; OR, 2.27; 95% CI,1.05-4.9; p=0.036) (Table 2). While median number of doses were higher [4 (IQR, 2-6) vs. 2 (IQR, 1-4)], the WBD group had lower cumulative exposure by 250% (Table 3). The WBD group experienced a 1.5 g/dL increase in baseline Hgb compared to a 1.2 g/dL increase in the HFD group. There was a trend for higher median MDRD6 at 12 weeks with the WBD group [53 mL/min/1.73m² (IQR, 37.0-67.9) vs. 46.6 mL/min/1.73m² (IQR, 31.6-60.1)]. Regarding safety, there were 3 VTE events and 1 death in the WBD group and 2 VTE events and 2 deaths in the HFD group.

*Conclusions: This study demonstrates that WBD of DA in RTR with PTA is significantly associated with a higher incidence of achieving a Hgb > 10 g/dL and freedom from blood transfusion compared to HFD despite lower cumulative DA exposure. Rates of adverse events were also similar between both groups. This study highlights that WBD of DA in PTA is safe and effective, with potential for significant patient and health-system cost savings.

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