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Trends in Anemia Management among US Hemodialysis Patients

Joseph A. Coladonato^*, Diane L. Frankenfield, Donal N. Reddan^*, Preston S. Klassen^*, Lynda A. Szczech^*, Curtis A. Johnson and William F. Owen, Jr.^* for CMS ESRD Clinical Performance Measures Workgroup

*Duke Institute of Renal Outcomes Research and Health Policy, Duke University Medical Center, Durham, North Carolina; Office of Clinical Quality and Standards, Centers for Medicare and Medicaid Services, Baltimore, Maryland; University of Wisconsin School of Pharmacy, Madison, Wisconsin.

Correspondence to: Dr. John Stivelman served as guest editor and supervised the review and final disposition of this manuscript.Correspondence to: Dr. Joseph A. Coladonato, Duke Institute of Renal Outcomes Research and Health Policy, Box 3646, Duke University Medical Center, Durham, North Carolina 27710. Phone: 919-668-8008, Fax: 919-668-7128; E-mail joe.coladonato{at}duke.edu

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 ± 5.2% to 34.1 ± 3.7% and from 58.2 ± 41.8 U/kg to 68.2 ± 55.0 U/kg, respectively (P = 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 = 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 < 0.01). Conversely, intravenous EPO and iron were associated with higher prescribed EPO doses (all P = 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.

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