Effects of proactive iron and erythropoiesis-stimulating agent protocol implementation on achieving clinical guideline targets for anaemia in a satellite haemodialysis patient cohort

Nephrology (Carlton). 2010 Apr;15(3):288-93. doi: 10.1111/j.1440-1797.2009.01184.x.


Aim: Anaemia management with erythropoiesis-stimulating agents (ESA) and i.v. iron replacement in haemodialysis patients poses several clinical challenges, including maintaining stable haemoglobin (Hb) levels within target ranges while achieving lowest effective ESA dose. This manuscript describes the effect of implementing proactive protocol-driven adjustments for iron and ESA in maintenance haemodialysis patients.

Methods: This was a cohort study of 46 satellite haemodialysis patients examined from 2004 to 2006 with protocol implementation in 2005. Baseline haemoglobin, transferrin saturations (TSAT), ferritin values and ESA administration were obtained during 2004. Follow-up data was collected in 2006 and compared to baseline values in reference to specified targets in the 2004 Caring for Australasians with Renal Impairment (CARI) guidelines.

Results: Fifty-four percent of patients achieved haemoglobin targets during follow up versus 43% patients during baseline. Seventy-nine percent of patients achieved TSAT targets during follow up versus 67% patients during baseline. Ninety percent of patients achieved ferritin targets during follow up versus 75% patients during baseline. Odds ratios for values falling within target ranges during follow up compared to baseline were 1.63 (Hb: P = 0.037; 95% confidence interval (CI), 1.03-2.57), 1.90 (TSAT: P = 0.006; 95% CI, 1.20-3.01) and 3.72 (ferritin: P = 0.003; 95% CI, 1.57-8.83). There was a trend toward lower average ESA dose (P = 0.07).

Conclusion: This study demonstrates the successful implementation and efficacy of a proactive protocol for iron and ESA treatment in haemodialysis patients. Benefits include increased concordance with historical guideline targets and decreased haemoglobin variability. Improved iron status and optimizing ESA response allows for lower ESA doses, limiting both potential side-effects of ESA (hypertension) and the burgeoning costs of anaemia management.

MeSH terms

  • Anemia / blood
  • Anemia / drug therapy*
  • Anemia / etiology
  • Biomarkers
  • Clinical Protocols
  • Cohort Studies
  • Community Health Centers*
  • Darbepoetin alfa
  • Epoetin Alfa
  • Erythropoiesis / drug effects*
  • Erythropoietin / administration & dosage*
  • Erythropoietin / adverse effects
  • Erythropoietin / analogs & derivatives*
  • Ferric Compounds / administration & dosage*
  • Ferric Compounds / adverse effects
  • Ferritins / blood
  • Guideline Adherence
  • Hematinics / administration & dosage*
  • Hematinics / adverse effects
  • Hemoglobins / metabolism
  • Humans
  • Infusions, Intravenous
  • Kidney Failure, Chronic / blood
  • Kidney Failure, Chronic / complications
  • Kidney Failure, Chronic / therapy*
  • Odds Ratio
  • Practice Guidelines as Topic
  • Recombinant Proteins
  • Renal Dialysis*
  • Retrospective Studies
  • Time Factors
  • Transferrin / metabolism
  • Treatment Outcome
  • Western Australia


  • Biomarkers
  • Ferric Compounds
  • Hematinics
  • Hemoglobins
  • Recombinant Proteins
  • Transferrin
  • Erythropoietin
  • Darbepoetin alfa
  • Epoetin Alfa
  • Ferritins