Article

Implications of a reduction in the hemoglobin target in erythropoiesis-stimulating agent-treated hemodialysis patients.

Arnold and Marie Schwartz College of Pharmacy and Health Sciences-Long Island University and Mount Sinai Medical Center, New York, N.Y., USA.
Nephron extra 01/2011; 1(1):212-6. DOI:10.1159/000334228 pp.212-6
Source: PubMed

ABSTRACT Patients treated with erythropoiesis-stimulating agents (ESAs) to a hemoglobin (Hb) level >12.0 g/dl have increased risk of multiple complications, including death. The optimal Hb target for ESA use has not been established. We hypothesized that reducing the target Hb would prevent levels >12 g/dl and lead to significant cost savings.
Our target Hb range was reduced to 9-11 g/dl from 10-12 g/dl. Thirty-five chronic hemodialysis (HD) patients received erythropoietin (EPO) and intravenous iron from January to December 2009. Data analysis included: Hb level, EPO dose, transferrin saturation and ferritin levels. EPO was administered via subcutaneous injection weekly or twice weekly.
The mean monthly Hb level changed from 11.2 to 10.6 g/dl. The percentages of patients with mean Hb >10.0, 12.0 and 13.0 g/dl were 82 ± 6.5, 10 ± 5.6 and 1.8 ± 1.9%, respectively. Weekly EPO dose decreased from 9,500 to 5,600 units, a 40% reduction per dose per patient and costs. The savings exceeded USD 60,000 per year for 35 patients. More than 80% of patients had transferrin saturation >20% and ferritin >200 ng/ml throughout the entire period.
Lowering the target Hb range to 9-11 g/dl in HD patients achieved quality anemia management, avoided values >12.0 g/dl and resulted in cost savings. A minimal reduction in quality of life and no change in cardiovascular morbidity or mortality would be expected. The study has important implications in the new American bundled reimbursement model.

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    Article: Correction of anemia with epoetin alfa in chronic kidney disease.
    Ajay K Singh, Lynda Szczech, Kezhen L Tang, Huiman Barnhart, Shelly Sapp, Marsha Wolfson, Donal Reddan
    [show abstract] [hide abstract]
    ABSTRACT: Anemia, a common complication of chronic kidney disease, usually develops as a consequence of erythropoietin deficiency. Recombinant human erythropoietin (epoetin alfa) is indicated for the correction of anemia associated with this condition. However, the optimal level of hemoglobin correction is not defined. In this open-label trial, we studied 1432 patients with chronic kidney disease, 715 of whom were randomly assigned to receive a dose of epoetin alfa targeted to achieve a hemoglobin level of 13.5 g per deciliter and 717 of whom were assigned to receive a dose targeted to achieve a level of 11.3 g per deciliter. The median study duration was 16 months. The primary end point was a composite of death, myocardial infarction, hospitalization for congestive heart failure (without renal replacement therapy), and stroke. A total of 222 composite events occurred: 125 events in the high-hemoglobin group, as compared with 97 events in the low-hemoglobin group (hazard ratio, 1.34; 95% confidence interval, 1.03 to 1.74; P=0.03). There were 65 deaths (29.3%), 101 hospitalizations for congestive heart failure (45.5%), 25 myocardial infarctions (11.3%), and 23 strokes (10.4%). Seven patients (3.2%) were hospitalized for congestive heart failure and myocardial infarction combined, and one patient (0.5%) died after having a stroke. Improvements in the quality of life were similar in the two groups. More patients in the high-hemoglobin group had at least one serious adverse event. The use of a target hemoglobin level of 13.5 g per deciliter (as compared with 11.3 g per deciliter) was associated with increased risk and no incremental improvement in the quality of life. (ClinicalTrials.gov number, NCT00211120 [ClinicalTrials.gov].).
    New England Journal of Medicine 12/2006; 355(20):2085-98. · 53.30 Impact Factor
Data provided are for informational purposes only. Although carefully collected, accuracy cannot be guaranteed. The impact factor represents a rough estimation of the journal's impact factor and does not reflect the actual current impact factor. Publisher conditions are provided by RoMEO. Differing provisions from the publisher's actual policy or licence agreement may be applicable.

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Keywords

35 patients
 
40% reduction
 
cardiovascular morbidity
 
Data analysis
 
EPO dose
 
erythropoiesis-stimulating agents
 
ESA use
 
ferritin levels
 
intravenous iron
 
mean monthly Hb level
 
minimal reduction
 
multiple complications
 
optimal Hb target
 
quality anemia management
 
significant cost savings
 
subcutaneous injection weekly
 
target Hb
 
target Hb range
 
transferrin saturation
 
Weekly EPO dose