Successful creation of an anemia management algorithm for hemodialysis patients

Abstract

IntroductionSeveral anemia guidelines for hemodialysis patients have recommended a target hemoglobin (Hb) range of 10–12 g/dL. However, maintaining Hb values continuously within a narrow target has been difficult, and there has been no generally accepted anemia management algorithm for hemodialysis patients.MethodsIn our study, we created an anemia management algorithm that considers the length of erythrocyte lifetimes, focuses on the combination of erythropoiesis-stimulating agent management and iron administration, and prevents iron deficiency and overload. Our algorithm established a target Hb range of 10–12 g/dL.ResultsWe evaluated our algorithm in 49 patients for 6 months. The mean Hb values were approximately 11 g/dL during our study period. The percentage of patients in the target Hb range of 10–12 g/dL increased from 77.6% (38 of 49) at baseline to 85.7% (42 of 49) at 4–6 months. Throughout monthly regular blood tests during 1–6 months after we introduced our algorithm, Hb values remained within the target range in 55.1% (27 of 49) of patients. The standard deviation of Hb values significantly decreased at 5 and 6 months (P=0.013 and P=0.047, respectively; 1 g/dL at 0 month, 0.7 g/dL at 5 months, and 0.7 g/dL at 6 months). Our algorithm also succeeded in suppressing cumulative doses of iron (≤800 mg) and decreasing the ferritin values significantly (P=0.011). There were no significant differences in erythropoiesis-stimulating agent doses between 0 and 6 months (P=0.357).ConclusionOur anemia management algorithm successfully increased the number of patients in the target Hb range, significantly decreased the Hb standard deviation, suppressed cumulative doses of iron, and decreased ferritin values. These results suggest a better prognosis for hemodialysis patients. Further studies are required to evaluate our algorithm.

A pharmacist‐managed dosing algorithm for darbepoetin alfa and iron sucrose in hemodialysis patients: A randomized, controlled trial

“…In these studies in patients with different stages of CKD, pharmacist and algorithm-based interventions led to higher percentages of hemoglobin levels within the target range. [16][17][18][19]23 However, a comparison with our results is difficult, as the applied target ranges for hemoglobin in earlier studies were broader than recommended in the prevailing guidelines, and patients in our study were older and had more comorbidities. Most of the previous studies included only a small percentage of all assessed patients.…”

“…Although the good internal validity of this trial supports a firm conclusion in the study population, its external validity and applicability to other countries, such as the United States and Japan, need further investigation to verify the influence of healthcare structure and patient characteristics, such as ferritin levels, dialysis vintage, and intrapatient hemoglobin variability, which are known to be highly variable between regions worldwide. 17,18,25,28 Although recent changes in hemoglobin target range hamper direct extrapolation and use of existing algorithms in current practice, this trial shows that our intervention is effective in improving the percentage per patient in the target range for hemoglobin.…”

“…15 Improvement of guideline adherence for ESA prescribing may reduce the risk of complications. Various interventions to improve ESA prescribing have shown promising results in patients with CKD, eg the introduction of treatment algorithms, 16,17 and pharmacist-managed anemia programs. [18][19][20][21] However, all published trials have low patient numbers, a relatively short follow-up and often an observational design.…”

Development and Validation of a Treatment Algorithm for Osteoarthritis Pain Management in Patients With End-Stage Kidney Disease Undergoing Hemodialysis

“…To the study team’s knowledge, this is the first validated algorithm for osteoarthritis pain management in the hemodialysis population. Similar algorithms and tools have been developed to guide treatment in other areas of kidney disease management such as anemia, 48 constipation, 49 uremic pruritus, 38 hyperphosphatemia, 50 and mineral bone disorder. 51 Studies which evaluated the impact of such tools have demonstrated their utility in improving the overall quality of health care.…”

Development and validation of a constipation treatment toolkit for patients on hemodialysis

“…In patients with chronic kidney disease, secondary comorbidities are often multifactorial in nature and treatments must be selected with altered pharmacokinetics and potential for toxicity in mind. To the best of our knowledge, there are few treatment algorithms developed specifically for patients on HD, and even fewer that have been validated, implemented, and evaluated 26–29 . It is important that future research encompasses the implementation and evaluation of treatment algorithms to verify the utility and effectiveness of these designed tools.…”