The DOPPS Practice Monitor for US Dialysis Care: Trends Through December 2011

From August 2010 to December 2011, anemia management has undergone substantial changes. Significant reductions in intravenous epoetin doses and declines in Hb levels in the latter half of 2011 suggest that changes in regulatory guidance (such as the June ESA label change) exerted a larger influence on reducing ESA doses than changes in payment introduced at the beginning of 2011.There has been a substantial shift toward lower Hb levels from 2010 to 2011. Although the largest change in distribution was from ≥12 to 10-10.9 g/dL, the percentage of patients with Hb <10 g/dL increased to 16% by December 2011. Notably, patients with Hb <10 g/dL had the largest decline in prescribed epoetin doses and similar intravenous iron prescription patterns to other patients. This finding is consistent with lower ceiling epoetin doses, lower Hb targets, and tolerance of lower Hb levels in general; however, in the context of reports of rising transfusion rates (often occurring in hospitals and potentially outside the nephrologist's control), we believe this represents an opportunity to improve care. Accordingly, we suggest nephrologists give consideration to raising epoetin dose and intravenous iron use in many of these patients to limit avoidable transfusions. We have also observed increases in intravenous iron utilization along with a large rise in serum ferritin levels in 2011, to a median value of nearly 700 ng/mL. The consequences of greater iron dosing and high cumulative iron doses over time merit urgent study. Until then, clinical caution is warranted. ©2013 by the National Kidney Foundation, Inc.