Weinhandl Eric D, Eggert William, Hwang Yunji, Gilbertson David T, Petersen Jeffrey
Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota, USA.
Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.
Kidney Int Rep. 2023 Sep 7;8(12):2616-2624. doi: 10.1016/j.ekir.2023.09.009. eCollection 2023 Dec.
The treatment of anemia is a major activity in the care of patients undergoing maintenance hemodialysis (HD). The comparative effectiveness of new pharmacologic treatments, relative to erythropoiesis-stimulating agents (ESAs), should be anticipated on the bases of controlled trials and current practice. We describe the contemporary practice of anemia treatment in a national cohort of patients undergoing maintenance HD.
We analyzed the United States Renal Data System (USRDS) data to identify adult patients undergoing in-facility HD in 2016 to 2019. Using the Consolidated Renal Operations in a Web-Enabled Network (CROWNWeb) dataset, we identified hemoglobin and ESA utilization (agent and cumulative dose) during each patient-month, as well as intravenous (IV) iron utilization, ferritin, and transferrin saturation. We compared ESA dosing during the study era to dosing in the Normal Hematocrit Cardiac Trial (NHCT), conducted in the 1990s. We assessed ESA hyporesponsiveness by estimating the prevalence of the following: (i) high erythropoietin resistance index (ERI) and (ii) either 3 or 6 consecutive months with hemoglobin <10 g/dl.
Nearly two-thirds of patient-months had hemoglobin of 10.0 to 11.9 g/dl. Mean ESA utilization was 76.7% per month, with increasing use of pegylated epoetin beta. ESA dosing was stable; epoetin alfa dosing was slightly lower than in the low-target arm of the NHCT. The prevalence of ESA hyporesponsiveness was 22.2% if defined by high ERI, but only 2.1% to 6.0% if defined by 3 to 6 consecutive months with hemoglobin <10 g/dl. Median transferrin saturation was 22.3% with high ERI and persistently low hemoglobin.
Hemoglobin and ESA dosing distributions are stable, with epoetin alfa dosing below the low-target arm of the NHCT. Persistently low hemoglobin occurs infrequently and may reflect iron depletion.
贫血治疗是维持性血液透析（HD）患者护理中的一项主要工作。相对于促红细胞生成素（ESA），新的药物治疗的相对有效性应基于对照试验和当前实践来预期。我们描述了全国维持性HD患者队列中贫血治疗的当代实践情况。
我们分析了美国肾脏数据系统（USRDS）的数据，以确定2016年至2019年期间接受院内HD的成年患者。使用基于网络的综合肾脏操作（CROWNWeb）数据集，我们确定了每个患者月的血红蛋白和ESA使用情况（药物和累积剂量），以及静脉注射（IV）铁的使用情况、铁蛋白和转铁蛋白饱和度。我们将研究期间的ESA剂量与20世纪90年代进行的正常血细胞比容心脏试验（NHCT）中的剂量进行了比较。我们通过估计以下情况的患病率来评估ESA低反应性：（i）高促红细胞生成素抵抗指数（ERI）和（ii）血红蛋白连续3个月或6个月<10 g/dl。
近三分之二的患者月血红蛋白为10.0至11.9 g/dl。平均每月ESA使用率为76.7%，聚乙二醇化促红细胞生成素β的使用增加。ESA剂量稳定；促红细胞生成素α的剂量略低于NHCT低目标组。如果根据高ERI定义，ESA低反应性的患病率为22.2%，但如果根据血红蛋白连续3至6个月<10 g/dl定义，患病率仅为2.1%至6.0%。高ERI和持续低血红蛋白时转铁蛋白饱和度中位数为22.3%。
血红蛋白和ESA剂量分布稳定，促红细胞生成素α剂量低于NHCT低目标组。持续低血红蛋白情况很少发生，可能反映铁缺乏。
