Use of Clinical Guidelines for Treatment of Anemia Among Hemodialysis Patients

Abstract

Changing financial incentives have strongly influenced dosing patterns of recombinant human erythropoietin (rHuEPO) since its introduction in 1989. Although guidelines for prescribing rHuEPO exist, the extent to which they are adhered to is unknown. Using a retrospective cohort observational study design, the factors influencing the initial dosing of rHuEPO prescribed to 413 hemodialysis patients in 1994 were examined. Patient weight, the only recommended guideline, was not found to be a significant predictor of dosing of rHuEPO after controlling for selected patient demographic and clinical characteristics. The strongest predictor for initial rHuEPO dosing was hematocrit followed by White race (p < 0.05). Finally, each subsequent month was associated with a significantly larger initial rHuEPO dose, reflecting the general trend in increasing dose since 1991 (p < 0.001). In conclusion, despite the recent DOQI guidelines for treatment of anemia among persons with chronic renal failure, providers are not using patient weight as an independent criterion for determining dosing of rHuEPO.

Effect of malnutrition-inflammation complex syndrome on EPO hyporesponsiveness in maintenance hemodialysis patients

“…5, 6 However, many dialysis patients, despite adequate iron supplementation, still require inappropriately higher doses of EPO. 2,[7][8][9] Refractory anemia appears to be more common in those dialysis patients who also suffer from protein-energy malnutrition (PEM) or inflammation. [10][11][12] Because inflammation and PEM have a high prevalence and are found to be closely related to each other in dialysis patients, together they are also referred to as malnutrition-inflammation complex syndrome (MICS).…”

Septicemia in Patients with ESRD Is Associated with Decreased Hematocrit and Increased Use of Erythropoietin

“…In some patients, this incomplete response is due to iron deficiency (5,6). Despite adequate iron supplementation, certain dialysis patients still may require unexpectedly high dosages of EPO (so-called "EPO hyporesponsiveness") (4,(7)(8)(9). Several studies have shown that inflammation causes EPO hyporesponsiveness (5,10 -12).…”