Rogers Jenelle, Leung Marianna, Beaulieu Monica, Levin Adeera, Burnett Shelley, Zienkiewicz Anita
, BScChem, BScPharm, ACPR, is a Clinical Pharmacist, St Paul's Hospital, Providence Healthcare, Vancouver, British Columbia.
Can J Hosp Pharm. 2011 Mar;64(2):141-6. doi: 10.4212/cjhp.v64i2.998.
Anemia commonly develops in patients with chronic kidney disease and is strongly associated with adverse clinical outcomes. There are currently no published studies evaluating the efficacy of a nurse-driven anemia-management protocol for patients with chronic kidney disease who are not receiving dialysis.
To evaluate the efficacy of an anemia-management protocol in terms of achieving hemoglobin and transferrin saturation levels within the target range, as well as associated utilization of medications, relative to individualized dosing of medications by nephrologists.
An algorithm for nurse-driven management of anemia was introduced in April 2009 at a kidney function clinic in a large urban centre. The charts of patients with chronic kidney disease who were not undergoing dialysis were reviewed before (July to December 2007) and after (July to December 2009) implementation of the protocol. Patients' data for hemoglobin, transferrin saturation, and doses of iron and erythropoiesis-stimulating agents were collected for each of the 6-month study periods.
In total, 390 patients were treated for anemia before and 434 patients after introduction of the protocol. The anemia-management protocol was non-inferior to individualized dosing for maintenance of hemoglobin levels within the target range of 110-120 g/L: percentage of measured levels within target range 33.3% (485/1456) before versus 34.2% (504/1472) after (absolute difference 0.9 percentage points, 95% confidence interval [CI] -2.5 to 4.4). The criteria for non-inferiority were not met for maintenance of transferrin saturation within the target range of 22%-50%: percentage of levels within target range 58.8% (374/636) before versus 56.9% (403/708) after (absolute difference 1.9 percentage points, 95% CI -3.4 to 7.2). There were no statistically significant differences in mean doses of epoetin alfa, darbepoetin, or iron before and after introduction of the protocol. Similarly, there were no statistically significant differences in number of dose changes for epoetin alfa, darbepoetin, or iron.
The nurse-driven anemia-management protocol was non-inferior to dosing by nephrologists in terms of managing hemoglobin levels. It would be reasonable to use an anemia-management protocol for patients with chronic kidney disease who are not receiving dialysis.
贫血在慢性肾脏病患者中普遍存在，且与不良临床结局密切相关。目前尚无已发表的研究评估针对未接受透析的慢性肾脏病患者实施护士主导的贫血管理方案的疗效。
相对于肾脏病医生的个体化药物剂量调整，评估贫血管理方案在使血红蛋白和转铁蛋白饱和度水平达到目标范围方面的疗效，以及相关药物的使用情况。
2009年4月，在一个大型城市中心的肾功能诊所引入了护士主导的贫血管理算法。对未接受透析的慢性肾脏病患者在方案实施前（2007年7月至12月）和实施后（2009年7月至12月）的病历进行回顾。在每个为期6个月的研究期间收集患者的血红蛋白、转铁蛋白饱和度以及铁剂和促红细胞生成剂剂量的数据。
方案实施前共有390例患者接受贫血治疗，实施后有434例。在将血红蛋白水平维持在110 - 120 g/L的目标范围内，贫血管理方案不劣于个体化剂量调整：测量水平在目标范围内的百分比，实施前为33.3%（485/1456），实施后为34.2%（504/1472）（绝对差异0.9个百分点，95%置信区间[CI] -2.5至4.4）。在将转铁蛋白饱和度维持在22% - 50%的目标范围内未达到非劣效性标准：水平在目标范围内的百分比，实施前为58.8%（374/636），实施后为56.9%（403/708）（绝对差异1.9个百分点，95% CI -3.4至7.2）。方案实施前后促红细胞生成素α、促红细胞生成素β或铁剂的平均剂量无统计学显著差异。同样，促红细胞生成素α、促红细胞生成素β或铁剂的剂量变化次数也无统计学显著差异。
在管理血红蛋白水平方面，护士主导的贫血管理方案不劣于肾脏病医生的剂量调整。对于未接受透析的慢性肾脏病患者，使用贫血管理方案是合理的。
