Department of Renal Medicine, Sydney West Area Health Service, Westmead Hospital, Hawkesbury Road, Westmead, Australia.
Nephrology (Carlton). 2010 Apr;15(3):288-93. doi: 10.1111/j.1440-1797.2009.01184.x.
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.
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.
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).
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.
在血液透析患者中使用促红细胞生成素刺激剂（ESA）和静脉铁剂替代治疗贫血会带来一些临床挑战，包括在达到目标范围内的稳定血红蛋白（Hb）水平的同时，实现最低有效 ESA 剂量。本文描述了在维持性血液透析患者中实施积极主动的基于方案的铁剂和 ESA 调整的效果。
这是一项 2004 年至 2006 年对 46 名卫星血液透析患者进行的队列研究，2005 年实施了方案。在 2004 年获得基线血红蛋白、转铁蛋白饱和度（TSAT）、铁蛋白值和 ESA 给药。在 2006 年收集随访数据，并与 2004 年澳大利亚肾脏损害患者护理（CARI）指南中的特定目标进行比较。
54%的患者在随访期间达到了血红蛋白目标，而在基线期间为 43%的患者。79%的患者在随访期间达到了 TSAT 目标，而在基线期间为 67%的患者。90%的患者在随访期间达到了铁蛋白目标，而在基线期间为 75%的患者。与基线相比，随访期间数值在目标范围内的比值比（OR）为 1.63（Hb：P=0.037；95%置信区间（CI），1.03-2.57），1.90（TSAT：P=0.006；95%CI，1.20-3.01）和 3.72（铁蛋白：P=0.003；95%CI，1.57-8.83）。ESA 平均剂量呈下降趋势（P=0.07）。
本研究证明了在血液透析患者中积极主动的铁剂和 ESA 治疗方案的成功实施和有效性。益处包括提高与历史指南目标的一致性和降低血红蛋白变异性。改善铁状态和优化 ESA 反应可降低 ESA 剂量，既限制了 ESA 的潜在副作用（高血压），又限制了贫血管理的不断增加的成本。
