Changing patterns of anemia management in US hemodialysis patients

Erythropoiesis-stimulating agents and adjuvant intravenous iron have been the primary treatment for anemia in chronic kidney disease. Recent clinical and policy-related events have challenged this traditional paradigm, particularly in regard to erythropoiesis-stimulating agents. Less is known about the impact of these events on intravenous iron use.

United States Renal Data System data (2002-2008) on Medicare hemodialysis patients were examined. For each patient, monthly intravenous iron dose, erythropoiesis-stimulating agent dose, and hemoglobin values were determined. Data were summarized by calendar quarter and plotted for the entire sample and by demographic, clinical, and facility-level subgroups. Marginal means for these variables also were computed to account for changes in patient characteristics over time.

Quarterly iron use increased from 64% in 2002 to 76% in 2008. Mean quarterly iron dose increased from 500 mg in 2002 to 650 mg in 2008. Mean monthly erythropoiesis-stimulating agent dose (per quarter) increased from 2002 to 2006 and then declined. Mean hemoglobin values followed a pattern similar to erythropoiesis-stimulating agent dose. The same patterns in iron, erythropoiesis-stimulating agent dose, and hemoglobin were generally observed across demographic, clinical, facility, and geographic subgroups, with some important differences between subgroups, specifically race and dialysis vintage.

Anemia management patterns have changed markedly between 2002 and 2008, with a steady increase in intravenous iron use even after declines in erythropoiesis-stimulating agent dose and hemoglobin. The clinical impacts of these changes need further evaluation.