Clinical Factors and the Decision to Transfuse Chronic Dialysis Patients

Abstract

SummaryBackground and objectives Red blood cell transfusion was previously the principle therapy for anemia in CKD but became less prevalent after the introduction of erythropoiesis-stimulating agents. This study used adaptive choice-based conjoint analysis to identify preferences and predictors of transfusion decision-making in CKD.Design, setting, participants, & measurements A computerized adaptive choice-based conjoint survey was administered between June and August of 2012 to nephrologists, internists, and hospitalists listed in the American Medical Association Masterfile. The survey quantified the relative importance of 10 patient attributes, including hemoglobin levels, age, occult blood in stool, severity of illness, eligibility for transplant, iron indices, erythropoiesis-stimulating agents, cardiovascular disease, and functional status. Triggers of transfusions in common dialysis scenarios were studied, and based on adaptive choice-based conjoint-derived preferences, relative importance by performing multivariable regression to identify predictors of transfusion preferences was assessed.Results A total of 350 providers completed the survey (n=305 nephrologists; mean age=46 years; 21% women). Of 10 attributes assessed, absolute hemoglobin level was the most important driver of transfusions, accounting for 29% of decision-making, followed by functional status (16%) and cardiovascular comorbidities (12%); 92% of providers transfused when hemoglobin was 7.5 g/dl, independent of other factors. In multivariable regression, Veterans Administration providers were more likely to transfuse at 8.0 g/dl (odds ratio, 5.9; 95% confidence interval, 1.9 to 18.4). Although transplant eligibility explained only 5% of decision-making, nephrologists were five times more likely to value it as important compared with non-nephrologists (odds ratio, 5.2; 95% confidence interval, 2.4 to11.1).Conclusions Adaptive choice-based conjoint analysis was useful in predicting influences on transfusion decisions. Hemoglobin level, functional status, and cardiovascular comorbidities most strongly influenced transfusion decision-making, but preference variations were observed among subgroups.

Trends in Anemia Care in Older Patients Approaching End-Stage Renal Disease in the United States (1995-2010)

“…Apparently, providers (nephrologists, internists, hospitalists) consider hemoglobin the single most important factor in their decisions to transfuse, with clinical factors such as functional status and cardiovascular comorbidities playing a much lesser role. 26 In patients on dialysis, increases between 2006 and 2010 in the proportion of patients whose hemoglobin concentration was below 10 g/dL have been linked to increased transfusion rates during the same time period, which was independent of any other recorded clinical factors. 27 …”

International Comparisons to Assess Effects of Payment and Regulatory Changes in the United States on Anemia Practice in Patients on Hemodialysis: The Dialysis Outcomes and Practice Patterns Study

“…United States ESA dosing guidance before 2011 recommended treating patients with CKD to an Hb level between 10 and 12 g/dl (well above common thresholds for using red blood cell transfusions to correct severe anemia) 35,36 and may have led to administration of higher doses than necessary in Doses expressed as iv epoetin-equivalent units per week were calculated using the following conversions: subcutaneous epoetin (31. ESA-resistant patients.…”

Hospitalization Among Individuals Waitlisted For Kidney Transplant

“…PRA increases in individuals who receive multiple prior transfusions or other exposures to foreign antigens. Among dialysis patients, those with more comorbidities may be more likely to be selected for transfusion 27 , suggesting that these individuals may be sicker at baseline. Unfortunately, this also increases the likelihood of alloimmunization and the difficulty of finding a suitable organ match 28 and leaves these individuals waiting longer for an organ.…”