Trends in anemia management in US hemodialysis patients 2004-2010

Abstract

Background: There have been major changes in the management of anemia in US hemodialysis patients in recent years. We sought to determine the influence of clinical trial results, safety regulations, and changes in reimbursement policy on practice.

Methods: We examined indicators of anemia management among incident and prevalent hemodialysis patients from a medium-sized dialysis provider over three time periods: (1) 2004 to 2006 (2) 2007 to 2009, and (3) 2010. Trends across the three time periods were compared using generalized estimating equations.

Results: Prior to 2007, the median proportion of patients with monthly hemoglobin >12 g/dL for patients on dialysis 0 to 3, 4 to 6 and 7 to 18 months, respectively, was 42%, 55% and 46% declined to 41%, 54%, and 40% after 2007, and declined more sharply in 2010 to 34%, 41%, and 30%. Median weekly Epoeitin alpha doses over the same periods were 18,000, 12,400, and 9,100 units before 2007; remained relatively unchanged from 2007 to 2009; and decreased sharply in the patients 3-6 and 6-18 months on dialysis to 10,200 and 7,800 units, respectively in 2010. Iron doses, serum ferritin, and transferrin saturation levels increased over time with more pronounced increases in 2010.

Conclusion: Modest changes in anemia management occurred between 2007 and 2009, followed by more dramatic changes in 2010. Studies are needed to examine the effects of declining erythropoietin use and hemoglobin levels and increasing intravenous iron use on quality of life, transplantation rates, infection rates and survival.

Figure 1

Multivariable adjusted Hb and EPO doses 2004-2010 among patients 0–3, 4–6 and 7–18 months on dialysis. Panel (a) Percentages of patients with Hb < 10 g/dL; Panel (b) Percentages of patients with Hb > 12 g/dL; Panel (c) Weekly EPO doses. Vales are based on white males greater than 65 years old with diabetes as the cause of ESRD. The slopes represent monthly rates of change during each of the three time periods (2004–2006, 2007–2009 and 2010). The “*” indicate that the slope is significantly different from 0. The grey dotted lines are 95% confidence intervals for the adjusted values. The difference in slopes for Hb < 10, Hb >10 g/dL and EPO dose within each ‘time on dialysis’ subgroup between 2004–2006 and 2007–2009 and between 2007–2009 and 2010 were statistically significant except for Hemoglobin < 10 g/dL in the 4–6 month patient subgroup between 2007–2009 and 2010.

Figure 2

Multivariable adjusted iron doses and markers of iron stores 2004-2010 among patients 0–3, 4–6, and 7–18 months on dialysis. Panel (a) Monthly iron dose (mg); Panel (b) Serum ferritin (ng/ml); Panel (c) TSat (%). Values are based on white males greater than 65 years old with diabetes as the cause of ESRD. The slopes represent monthly rates of change for each of the three time periods (2004–2006, 2007–2009 and 2010). The “*” indicate that the slope is significantly different from 0. The grey dotted lines are 95% confidence intervals for the predicted values. The difference in slopes between 2004–2006 and 2007–2009 and between 2007–2009 and 2010 are statistically significant within each ‘time on dialysis’ subgroup for each of the parameters except for the comparisons of monthly iron dose in the 0–3 month subgroup between 2007–2009 and 2010, and ferritin in the 0–3 month subgroup between 2004–2006 and 2007–2009.