Trends in Anemia Management among US Hemodialysis Patients

Abstract

Abstract. This study was undertaken to describe the relationship between hematocrit (Hct) and changes in the prescribed dose of erythropoietin (EPO) as well as selected patient and process care measures across annual national samples of hemodialysis patients from 1994 to 1998. This study uses the cohorts identified in the ESRD Core Indicators Project, random samples of 6181, 6241, 6364, 6634, and 7660 patients, stratified by ESRD Networks drawn for each year from 1994 to 1998. Patient demographic and clinical information was collected from October to December for each year. Surrogates of iron stores and patterns of iron and EPO administration were profiled from 1996 to 1998. Multivariable stepwise linear regression analyses were performed to adjust for potential confounding variables and to identify independent variables associated with Hct and EPO dose. Mean Hct and EPO dose increased each year from 31.1 Ϯ 5.2% to 34.1 Ϯ 3.7% and from 58.2 Ϯ 41.8 U/kg to 68.2 Ϯ 55.0 U/kg, respectively (P ϭ 0.0001). Increasing Hct was positively associated with male gender, more years on dialysis, older age, higher urea reduction ratio and transferrin saturation, prescription of intravenous iron, and lower ferritin and EPO dose in multivariable models (all P ϭ 0.0001). Male gender, older age, diabetes, higher Hct, and increasing weight, urea reduction ration, and transferrin saturation were associated with lower EPO doses (all P Ͻ 0.01). Conversely, intravenous EPO and iron were associated with higher prescribed EPO doses (all P ϭ 0.0001). Although increasing Hct is associated with decreasing EPO dose at the patient level, the increase in Hct seen across years among the cohorts of hemodialysis patients in the United States has been associated with increasing doses of EPO at the population level.

Administration of Parenteral Iron and Mortality among Hemodialysis Patients

“…The 2000 NKF-KDOQI guidelines recommend parenteral iron repletion for many hemodialysis (HD) patients whose hemoglobin levels are below target levels, and maintenance parenteral iron dosing is now recommended for the majority of HD patients. United States Renal Data System (USRDS) data reveal a steady increase in use of parenteral iron in incident and prevalent HD patients from 1994 to 1998 (4,5).…”

Anemia Management in Chronic Kidney Disease

“…The achievement of these favorable results has required increasing amounts of epoetin (1,4). On the one hand, there is a biologic need for more hormone to attain higher hematocrit levels; on the other hand, there are factors that can blunt the response to epoetin and therefore increase epoetin usage.…”

“…Coladonato et al (1) noted that a 17.2% increase in epoetin dose was needed to increase the hematocrit 9.7% from 31.1% to 34.1%. The authors consider this a disproportionate increase in epoetin and attempt to verify this by using a nonphysiologic term, "EPO Resistant Index".…”

“…Nevertheless, despite the nonlinear and biologically variable responses to either native or exogenous erythropoietin, Coladonato et al (1) have defined variable factors that influence epoetin responsiveness and its associated hematocrit response. Male gender, more years on dialysis, older age, higher urea reduction ratio (URR) and transferrin saturation, use of intravenous iron, and lower serum ferritin were noted to be favorably associated with higher hematocrit levels.…”

Possible Effects of the New Medicare Reimbursement Policy on African Americans with ESRD

“…Coladonato et al 12 also used the ESRD core indicator project and observed a similar difference in hematocrit between African Americans and whites (32.2 versus 32.6%), but no difference in EPO dose, after adjustment for predialysis weight. However, predialysis weights in their cohort were significantly higher for African Americans than whites, 11 suggesting that total EPO use may have been higher among African Americans.…”