Background: Anemia management in chronic hemodialysis (HD) has been affected by the implementation of the prospective payment system (PPS) and changes in clinical guidelines. These factors could impact red blood cell (RBC) transfusion in HD patients. Our distinctive care system contains complete records for all RBC transfusions among our HD patients. Aims: To determine RBC transfusions in patients with prevalent chronic HD, site of administration (inpatient or outpatient), and ordering physician specialty for inpatients; compare pre- and post-PPS RBC transfusions; and compare RBC transfusions during changes in desired outpatient hemoglobin (Hb) range for patients with chronic HD. Methods: Retrospective analysis of medical and blood bank records for patients with prevalent chronic HD July 2009 through June 2013. Results: In total, 310-356 patients were studied. Mean (SD) units of RBCs per 100 patients per month for the study's 48 months were outpatient, 2.6 (1.5), and inpatient, 9.4 (4.6). Outpatient pre-PPS RBC units transfused were 2.1 (0.6) vs. post-PPS of 2.6 (1.5; p = 0.22, t test); for inpatients pre-PPS, 7.9 (4.5) RBC units per month vs. post-PPS, 11.5 (5.1; p = 0.11, t test). Inpatient RBC transfusions accounted for 75.2% (14.2%) of all RBC transfusions; 67.3% (16.3%) of inpatient transfusions were ordered by nonnephrologists. Changes in desired Hb range for outpatient HD patients did not lead to changes in RBC transfusions. Conclusions: No changes in RBC transfusions occurred among our patients with chronic HD with PPS implementation and in desired Hb range during the study period. Most transfusions were given in inpatient settings by nonnephrologists.

Keywords:
Anemia, Chronic hemodialysis, End-stage renal disease, Red blood cell transfusions
1.
Eschbach JW, Egrie JC, Downing MR, Browne JK, Adamson JW: Correction of the anemia of end-stage renal disease with recombinant human erythropoietin. Results of a combined phase I and II clinical trial. N Engl J Med 1987;316:73-78.
2.
Ibrahim HN, Ishani A, Foley RN, Guo H, Liu J, Collins AJ: Temporal trends in red blood transfusion among US dialysis patients, 1992-2005. Am J Kidney Dis 2008;52:1115-1121.
3.
Gilbertson DT, Monda KL, Bradbury BD, Collins AJ: RBC transfusions among hemodialysis patients (1999-2010): influence of hemoglobin concentrations below 10 g/dL. Am J Kidney Dis 2013;62:919-928.
4.
KDOQI; National Kidney Foundation: KDOQI clinical practice guidelines and clinical practice recommendations for anemia in chronic kidney disease. Am J Kidney Dis 2006;47(5 suppl 3):S11-S145.
5.
Besarab A, Bolton WK, Browne JK, Egrie JC, Nissenson AR, Okamoto DM, Schwab SJ, Goodkin DA: The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoetin. N Engl J Med 1998;339:584-590.
6.
Drüeke TB, Locatelli F, Clyne N, Eckardt KU, Macdougall IC, Tsakiris D, Burger HU, Scherhag A; CREATE Investigators: Normalization of hemoglobin level in patients with chronic kidney disease and anemia. N Engl J Med 2006;355:2071-2084.
7.
Singh AK, Szczech L, Tang KL, Barnhart H, Sapp S, Wolfson M, Reddan D; CHOIR Investigators: Correction of anemia with epoetin alfa in chronic kidney disease. N Engl J Med 2006;355:2085-2098.
8.
Jenkins JK: Erythropoiesis-stimulating agents (ESA). Silver Springs, US Food and Drug Administration, 2007. http://www.fda.gov/newsevents/testimony/ucm110908.htm (accessed November 13, 2015).
9.
Aranesp (darbepoetin alfa) for injection. Thousand Oaks, Amgen Manufacturing, 2001-2007. www.accessdata.fda.gov/drugsatfda_docs/label/2007/103951s5164lbl.pdf (cited November 13, 2015).
10.
KDOQI: KDOQI clinical practice guideline and clinical practice recommendations for anemia in chronic kidney disease: 2007 update of hemoglobin target. Am J Kidney Dis 2007;50:471-530.
11.
Pfeffer MA, Burdmann EA, Chen CY, Cooper ME, de Zeeuw D, Eckardt KU, Feyzi JM, Ivanovich P, Kewalramani R, Levey AS, Lewis EF, McGill JB, McMurray JJ, Parfrey P, Parving HH, Remuzzi G, Singh AK, Solomon SD, Toto R; TREAT Investigators: A trial of darbepoetin alfa in type 2 diabetes and chronic kidney disease. N Engl J Med 2009;361:2019-2032.
12.
Aranesp (darbepoetin alfa) for injection. Thousand Oaks, Amgen Manufacturing, 2001-2010. www.accessdata.fda.gov/drugsatfda_docs/label/2010/103951s5197lbl.pdf (cited November 13, 2015).
13.
Aranesp (Darbepoetin Alfa) for Injection. Thousand Oaks, Amgen Manufacturing, 2001-2011 www.accessdata.fda.gov/drugsatfda_docs/label/2011/103951Orig1s5173_103951Orig1s5258lbl.pdf (cited November 13, 2015).
14.
KDIGO clinical practice guideline for anemia in chronic kidney disease. Kidney Int Suppl 2012;2:1-335.
15.
Moist LM, Troyanov S, White CT, Wazny LD, Wilson JA, McFarlane P, Harwood L, Sood MM, Soroka SD, Bass A, Manns BJ: Canadian society of nephrology commentary on the 2012 KDIGO clinical practice guideline for anemia in CKD. Am J Kidney Dis 2013;62:860-873.
16.
Centers for Medicare and Medicaid Services (CMS), HHS: Medicare program; end-stage renal disease prospective payment system. Final rule. Fed Regist 2010;75:49029-49214.
17.
Centers for Medicare and Medicaid Services (CMS), HHS: Medicare program; end-stage renal disease prospective payment system and quality incentive program; ambulance fee schedule; durable medical equipment; and competitive acquisition of certain durable medical equipment prosthetics, orthotics and supplies. Final rule. Fed Regist 2011;76:70228-70316.
18.
Collins AJ: ESRD payment policy changes: the new ‘bundled' dialysis prospective payment system (PPS) in the United States. Ann Arbor, United States Renal Data System. http://www.usrds.org/2012/pres/USDialysisBundle_impact_NKFCM2012.pdf (cited November 13, 2015).
19.
Brunelli SM, Monda KL, Burkart JM, Gitlin M, Neumann PJ, Park GS, Symonian-Silver M, Yue S, Bradbury BD, Rubin RJ: Early trends from the study to evaluate the prospective payment system impact on small dialysis organizations (STEPPS). Am J Kidney Dis 2013;61:947-956.
20.
Fuller DS, Pisoni RL, Bieber BA, Gillespie BW, Robinson BM: The DOPPS practice monitor for US dialysis care: trends through December 2011. Am J Kidney Dis 2013;61:342-346.
21.
Macdougall IC, Obrador GT: How important is transfusion avoidance in 2013? Nephrol Dial Transplant 2013;28:1092-1099.
22.
Tanhehco YC, Berns JS: Red blood cell transfusion risks in patients with end-stage renal disease. Semin Dial 2012;25:539-544.
23.
Rogers J, Gallaher EJ, Hocum C, Steensma DP, Chrisope TR, Dingli D, McCarthy JT: Individualized Medicine and Biophysical System Dynamics: An Example from Clinical Practice in End Stage Renal Disease. Washington, Proceedings of the 29th International Conference of the System Dynamics Society, July 25-29, 2011. http://www.systemdynamics.org/conferences/2011/proceed/papers/P1299.pdf (cited November 13, 2015).
24.
McCarthy JT, Hocum CL, Albright RC, Rogers J, Gallaher EJ, Steensma DP, Gudgell SF, Bergstralh EJ, Dillon JC, Hickson LJ, Williams AW, Dingli D: Biomedical system dynamics to improve anemia control with darbepoetin alfa in long-term hemodialysis patients. Mayo Clin Proc 2014;89:87-94.
25.
Pisoni RL, Fuller DS, Bieber BA, Gillespie BW, Robinson BM: The DOPPS practice monitor for US dialysis care: trends through August 2011. Am J Kidney Dis 2012;60:160-165.
26.
Ibrahim HN, Skeans MA, Li Q, Ishani A, Snyder JJ: Blood transfusions in kidney transplant candidates are common and associated with adverse outcomes. Clin Transplant 2011;25:653-659.
27.
Lawler EV, Bradbury BD, Fonda JR, Gaziano JM, Gagnon DR: Transfusion burden among patients with chronic kidney disease and anemia. Clin J Am Soc Nephrol 2010;5:667-672.
28.
Whitman CB, Shreay S, Gitlin M, van Oijen MG, Spiegel BM: Clinical factors and the decision to transfuse chronic dialysis patients. Clin J Am Soc Nephrol 2013;8:1942-1951.
© 2016 S. Karger AG, Basel
2016
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.