Reengineering clinical operations in a medical practice to optimize the management of anemia of chronic kidney disease

Pharmacotherapy. 2007 May;27(5):734-44. doi: 10.1592/phco.27.5.734.


Objectives: To describe the clinic design, clinical evaluations, and treatment approaches used in a multidisciplinary clinic for management of anemia of chronic kidney disease (CKD), and to evaluate several selected clinical outcomes associated with this approach to anemia management.

Setting: University-affiliated, division of nephrology, outpatient multidisciplinary model CKD clinic headed by a clinical pharmacist.

Patients: One hundred sixty-six patients with anemia of CKD who were referred by nephrologists and primary care providers to the multidisciplinary clinic from March 1, 2002-July 31, 2004.

Measurements and main results: Patients received darbepoetin alfa dosed on an every-other-week basis. If patients were already receiving once-weekly recombinant human erythropoietin (r-HuEPO), the darbepoetin alfa dose was calculated by using the darbepoetin alfa package insert conversion table. If patients were naïve to previous erythropoietic therapy, the darbepoetin alfa dose was either 60 microg or 0.7 microg/kg. The dose and frequency of darbepoetin alfa and oral iron supplements were adjusted to achieve the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) targets for hemoglobin levels and iron measures. The primary outcome analyzed was the proportion of patients with at least 30 days of treatment who achieved a target hemoglobin level of 11.0 g/dl or greater. Of 128 patients who received at least 30 days of treatment, 100 (78%) attained the hemoglobin level (mean +/- SD 11.7 +/- 7 g/dl). Ninety-nine of 128 patients were originally naïve to erythropoietic therapy; 77 (78%) of these 99 patients achieved the hemoglobin target in a mean +/- SD of 7.9 +/- 7.5 weeks. These data contrast with the data of 29 patients seen in the year previous to the reengineered clinic process, whereby only 12 (41%) of these comparable patients reached hemoglobin target with r-HuEPO therapy. Of the 77 previously erythropoietic-naïve patients, 82% were receiving darbepoetin alfa every other week, 14% every 3 weeks, and 4% every 4 weeks at the time the hemoglobin target was achieved. Oral iron administration significantly increased the chance of achieving the K/DOQI targets for hemoglobin and iron.

Conclusion: Redefining roles and practices of members of a clinical practice and reengineering processes for anemia management were effective in achieving and maintaining target hemoglobin and iron levels.

Publication types

  • Evaluation Study

MeSH terms

  • Aged
  • Ambulatory Care / methods
  • Ambulatory Care / organization & administration*
  • Anemia / drug therapy*
  • Anemia / etiology
  • Darbepoetin alfa
  • Erythropoietin / administration & dosage
  • Erythropoietin / analogs & derivatives
  • Erythropoietin / therapeutic use
  • Female
  • Ferrous Compounds / therapeutic use
  • Hematinics / administration & dosage
  • Hematinics / therapeutic use
  • Hemoglobins / drug effects
  • Humans
  • Iron / therapeutic use
  • Kidney Failure, Chronic / complications*
  • Male
  • Middle Aged
  • Patient Care Team / organization & administration*
  • Pharmacists
  • Polysaccharides / therapeutic use
  • Professional Role
  • Program Development
  • Quality Assurance, Health Care / organization & administration*


  • Ferrous Compounds
  • Hematinics
  • Hemoglobins
  • Polysaccharides
  • Erythropoietin
  • Darbepoetin alfa
  • Iron