Real-world treatment patterns of renal anemia in hemodialysis patients

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Abstract

A multicenter cohort study.

The DialysisNet was previously developed for the management of hemodialysis (HD) patients based on the American Society for Testing and Materials Continuity of Care Records by metadata transformation. DialysisNet is a dialysis patient management program created by using the personal health record care platform to overcome the problems of registry studies, in real-time.

Here, we aimed to investigate the pattern of treatment for renal anemia in HD patients using DialysisNet.

We performed a multicenter cohort study among HD patients who were treated at one of the three Korean university-affiliated hospitals from January 2016 to December 2016. Subjects were divided into 4 hemoglobin variability groups by quartiles. The variable anemia treatment pattern was reviewed. To determine renal anemia treatment patterns, we automatically collected information on the practice of anemia treatment patterns such as erythropoietin stimulating agent (ESA) doses and administration frequencies, and targeted hemoglobin maintenance rate. Individual hemoglobin variabilities were expressed as (standard deviations)/(√(n/[n–1]).

The records of 159 patients were analyzed (Hospital A: 35, Hospital B: 21, Hospital C: 103). Mean patients’ age was 65.6 ± 12.8 years, and 61.6% were men. Overall, hemoglobin level was 10.5[7.43;13.93] g/dL. 158 (99.3%) patients were using ESA; and overall, the epoetin alfa dose was 33,000[4000;136,800] U per week. Hemoglobin levels ( P = .206) and epoetin alfa doses were similar ( P = .924) for patients with different hemoglobin variabilities. The hemoglobin target maintenance rate was lower in the highest hemoglobin variability group than in the lowest variability group ( P = .045).

In this study, detailed information on the actual anemia treatment patterns were obtained using the DialysisNet. We expect that DialysisNet will simplify and improve the renal anemia management for both dialysis patients and health care providers.

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Most cited references 26

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Anemia management and outcomes from 12 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS).

Friedrich Port, Tadao Akizawa, José Cruz … (2004)

Anemia is common in hemodialysis (HD) patients. Data collected from nationally representative samples of HD patients (n = 11,041) in 2002 to 2003 were used to describe current anemia management for long-term HD patients at 309 dialysis units in 12 countries. Analyses of associations and outcomes were adjusted for demographics, 15 comorbid classes, laboratory values, country, and facility clustering. For patients on dialysis therapy for longer than 180 days, 23% to 77% had a hemoglobin (Hgb) concentration less than 11 g/dL ( or =110 g/L) if they were older; were men; had polycystic kidney disease; had greater albumin, transferrin saturation, or calcium levels; were not dialyzing with a catheter; or had lower ferritin levels. Facilities with greater intravenous iron use showed significantly greater facility mean Hgb concentrations. Mean EPO dose varied from 5,297 (Japan) to 17,360 U/wk (United States). Greater country mean EPO doses were significantly associated with greater country mean Hgb concentrations. Several patient characteristics were associated with greater EPO doses. Even in some countries with high intravenous iron use, 35% to 40% of patients had a transferrin saturation less than 20% (below guidelines). These findings indicate large international variations in anemia management, with significant improvements during the last 5 years, although many patients remain below current anemia guidelines, suggesting large and specific opportunities for improvement.

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Dose of erythropoiesis-stimulating agents and adverse outcomes in CKD: a metaregression analysis.

Mansour Alfayez, Ethan Balk, Bertrand Jaber … (2012)

Targeting higher hemoglobin levels with erythropoiesis-stimulating agents (ESAs) to treat the anemia of chronic kidney disease (CKD) is associated with increased cardiovascular risk. Metaregression analysis examining the association of ESA dose with adverse outcomes independent of target or achieved hemoglobin level. Patients with anemia of CKD irrespective of dialysis status. We searched MEDLINE (inception to August 2010) and bibliographies of published meta-analyses and selected randomized controlled trials assessing the efficacy of ESAs for the treatment of anemia in adults with CKD, with a minimum 3-month duration. Two authors independently screened citations and extracted relevant data. Individual study arms were treated as cohorts and constituted the unit of analysis. ESA dose standardized to a weekly epoetin alfa equivalent, and hemoglobin levels. All-cause and cardiovascular mortality, cardiovascular events, kidney disease progression, or transfusion requirement. 31 trials (12,956 patients) met the criteria. All-cause mortality was associated with higher (per epoetin alfa-equivalent 10,000-U/wk increment) first-3-month mean ESA dose (incidence rate ratio [IRR], 1.42; 95% CI, 1.10-1.83) and higher total-study-period mean ESA dose (IRR, 1.09; 95% CI, 1.02-1.18). First-3-month ESA dose remained significant after adjusting for first-3-month mean hemoglobin level (IRR, 1.48; 95% CI, 1.02-2.14), as did total-study-period mean ESA dose adjusting for target hemoglobin level (IRR, 1.41; 95% CI, 1.08-1.82). Parameter estimates between ESA dose and cardiovascular mortality were similar in magnitude and direction, but not statistically significant. Higher total-study-period mean ESA dose also was associated with increased rate of hypertension, stroke, and thrombotic events, including dialysis vascular access-related thrombotic events. Use of study-level aggregated data; use of epoetin alfa-equivalent doses; lack of adjustment for confounders. In patients with CKD, higher ESA dose might be associated with all-cause mortality and cardiovascular complications independent of hemoglobin level. Copyright © 2012 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

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Association between recombinant human erythropoietin and quality of life and exercise capacity of patients receiving haemodialysis. Canadian Erythropoietin Study Group.

(1990)

To determine whether recombinant human erythropoietin improves the quality of life and exercise capacity of anaemic patients receiving haemodialysis. A double blind, randomised, placebo controlled study. Eight Canadian university haemodialysis centres. 118 Patients receiving haemodialysis aged 18-75 with haemoglobin concentrations less than 90 g/l, no causes of anaemia other than erythropoietin deficiency, and no other serious diseases. Patients were randomised to three groups to receive placebo (n = 40), erythropoietin to achieve a haemoglobin concentration of 95-110 g/l (n = 40), or erythropoietin to achieve a haemoglobin concentration of 115-130 g/l (n = 38). Erythropoietin was given intravenously thrice weekly, initially at 100 units/kg/dose. The dose was subsequently adjusted to achieve the target haemoglobin concentration. All patients with a serum ferritin concentration less than 250 micrograms/l received oral or intravenous iron for one month before the study and as necessary throughout the trial. Scores obtained with kidney disease questionnaire, sickness impact profile, and time trade off technique; and results of six minute walk test and modified Naughton stress test. The mean (SD) haemoglobin concentration at six months was 74 (12) g/l in patients given placebo, 102 (10) g/l in those in the low erythropoietin group, and 117 (17) g/l in those in the high erythropoietin group. Compared with the placebo group, patients treated with erythropoietin had a significant improvement in their scores for fatigue, physical symptoms, relationships, and depression on the kidney disease questionnaire and in the global and physical scores on the sickness impact profile. The distance walked in the stress test increased in the group treated with erythropoietin, but there was no improvement in the six minute walk test, psychosocial scores on the sickness impact profile, or time trade off scores. There was no significant difference in the improvement in quality of life or exercise capacity between the two groups taking erythropoietin. Patients taking erythropoietin had a significantly increased diastolic blood pressure despite an increase in either the dose or number of antihypertensive drugs used. Eleven of 78 patients treated with erythropoietin had their sites of access clotted compared with only one of 40 patients given placebo. Patients receiving erythropoietin were appreciably less fatigued, complained of less severe physical symptoms, and had moderate improvements in exercise tolerance and depression compared with patients not receiving erythropoietin. At the doses used in this trial there was a higher incidence of hypertension and clotting of the vascular access in patients treated with erythropoietin.

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Author and article information

Journal

Journal ID (nlm-ta): Medicine (Baltimore)

Journal ID (iso-abbrev): Medicine (Baltimore)

Journal ID (publisher-id): MEDI

Title: Medicine

Publisher: Wolters Kluwer Health

ISSN (Print): 0025-7974

ISSN (Electronic): 1536-5964

Publication date Collection: January 2020

Publication date (Electronic): 10 January 2020

Volume: 99

Issue: 2

Electronic Location Identifier: e18749

Affiliations

[a ]Department of Internal Medicine, Pusan National University Hospital, Busan

[b ]Department of Internal Medicine, Kangwon National University School of Medicine

[c ]Department of Internal Medicine, Kangwon National University Hospital

[d ]Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, Ulsan

[e ]Department of Internal Medicine, Inje University Busan Paik Hospital

[f ]Seoul National University Biomedical Informatics (SNUBI), Division of Biomedical Informatics, Seoul National University College of Medicine

[g ]Department of Public Health Science, Graduate School of Public Health, Seoul National University

[h ]Institute of Life and Death Studies, Hallym University, Chuncheon

[i ]Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine

[j ]Systems Biomedical Informatics Research Center, Seoul National University

[k ]Center for Precision Medicine, Seoul National University Hospital, Seoul, Republic of Korea.

Author notes

[∗ ]Correspondence: Hoseok Koo, Department of Internal Medicine, Seoul Paik Hospital, 9, Mareunnae-ro, Jung-gu, 04551, Seoul, Republic of Korea (e-mail: hoseok.koo@ 123456gmail.com ); Ju Han Kim, Seoul National University Biomedical Informatics (SNUBI), Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, 03080, Seoul, Republic of Korea (e-mail: juhan@ 123456snu.ac.kr ).

Article

Publisher ID: MD-D-18-05923 Accession ID: 18749

DOI: 10.1097/MD.0000000000018749

PMC ID: 6959890

PubMed ID: 31914095

SO-VID: 6b8fd2ca-3082-413e-9ce3-d39045cfcb18

License:

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

History

Date received : 21 August 2018

Date revision received : 5 November 2019

Date accepted : 16 December 2019

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Keywords: anemia,dialysis,hemodialysis,real-world,treatment

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Keywords: anemia, dialysis, hemodialysis, real-world, treatment

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Real-world treatment patterns of renal anemia in hemodialysis patients : A multicenter cohort study performed using DialysisNet (RRAHD study)

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Most cited references 26

Anemia management and outcomes from 12 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS).

Dose of erythropoiesis-stimulating agents and adverse outcomes in CKD: a metaregression analysis.

Association between recombinant human erythropoietin and quality of life and exercise capacity of patients receiving haemodialysis. Canadian Erythropoietin Study Group.

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