Department of Pediatrics, Robert Larner, M.D. College of Medicine and the University of Vermont Children's Hospital, The University of Vermont, Burlington, VT, USA.
EMMES Corporation, Rockville, MD, USA.
Pediatr Nephrol. 2020 Feb;35(2):297-303. doi: 10.1007/s00467-019-04359-8. Epub 2019 Nov 10.
While adult hemodialysis (HD) patients have increased morbidity with higher target hemoglobin levels, similar findings have not been demonstrated in pediatric patients. We evaluated changes in transfusions, anemia frequency, and erythropoietin (epo) dosing among pediatric HD patients before, during, and after implementation of federal dialysis payment policies regarding epo dosing for adult HD patients.
This is a retrospective cohort study of pediatric HD patients enrolled in NAPRTCS. We evaluated need for transfusion, anemia, median hemoglobin, and median epo dose 6 months after starting HD in 3 eras: baseline (2003-2007), implementation (2008-2011), and post implementation (2012-2016). We used multivariate logistic regression models to evaluate potential differences in transfusion across the eras.
Six months after dialysis initiation, 12.6% of patients required transfusion pre-implementation, 17.9% during implementation, and 15.5% post implementation. Anemia occurred in 17.4% of patients pre, 23.5% during, and 23.8% post implementation, with median hemoglobin levels of 11.9 g/dL pre, 11 g/dL during, and 11 g/dL post implementation. Epo use was high across all 3 eras, but epo dosing decreased during and post implementation, despite more anemia during these periods. Odds of transfusion in implementation era compared with pre-implementation was 1.75 (95% CI 1.11-2.77) and odds of transfusion in post implementation era compared with pre was 1.19 (95% CI 0.71-1.98), controlling for age, race, gender, and prior transplant status.
During and following implementation of adult epo dosing guidelines, transfusion and anemia frequency increased in pediatric HD patients. Ideal target hemoglobin levels for pediatric dialysis patients warrant further study.
虽然接受血液透析（HD）治疗的成年患者血红蛋白水平较高时发病率增加，但在儿科患者中尚未发现类似的发现。我们评估了联邦透析支付政策实施前后儿科 HD 患者的输血、贫血频率和红细胞生成素（epo）剂量的变化，这些政策涉及成年 HD 患者的 epo 剂量。
这是一项对 NAPRTCS 注册的儿科 HD 患者的回顾性队列研究。我们评估了开始 HD 后 6 个月的输血需求、贫血、中位血红蛋白和中位 epo 剂量，共 3 个时期：基线（2003-2007 年）、实施（2008-2011 年）和实施后（2012-2016 年）。我们使用多变量逻辑回归模型评估各时期输血的潜在差异。
HD 起始后 6 个月，12.6%的患者在实施前需要输血，17.9%在实施期间需要输血，15.5%在实施后需要输血。17.4%的患者在实施前发生贫血，23.5%在实施期间发生贫血，23.8%在实施后发生贫血，中位血红蛋白水平分别为 11.9g/dL、11g/dL 和 11g/dL。在所有 3 个时期 epo 的使用量都很高，但在实施期间和之后 epo 的剂量减少，尽管在此期间贫血更为严重。与实施前相比，实施期间输血的几率为 1.75（95%CI 1.11-2.77），与实施前相比，实施后输血的几率为 1.19（95%CI 0.71-1.98），同时控制年龄、种族、性别和先前的移植状态。
在实施成人 epo 剂量指南期间和之后，儿科 HD 患者的输血和贫血频率增加。儿科透析患者的理想目标血红蛋白水平需要进一步研究。
