The well-documented decrease in prescribed doses of anemia drugs – 31% since January 2011––has lead to a corresponding increase in iron use and a significant increase in serum ferritin levels, researchers from the Dialysis Outcomes and Practice Patterns Study reported last month.
DOPPS has been monitoring changes in clinical indicators among dialysis clinics in the United States since the ESRD payment bundle became effective in 2011. The research group uses its Dialysis Practice Monitor to look at quality indicators among a sampling of 4,000 patients in 140 clinics around the country.
Based on findings as of April 2013, DOPPS reported at a Web Ex on Sept. 5 that:
- Sixty-seven to 70% of hemodialysis patients currently have active prescriptions for IV iron. Prior to the bundle (August 2010), 55% of patients were using IV iron. That increased to 68% by August 2011, declined to 56% in March 2012 and jumped 11 percentage points up to 67% by April 2012. The rate has remained steady over the past year.
- From August 2010 through August 2012, median serum ferritin levels in the sampling increased 40% to 795 ng/ml, with 15% of patients having ferritin levels >1,200 ng/mL. During the same time, median transferrin saturation (TSAT) levels increased from 28% to 29%, while the proportion of patients with TSAT < 20% fell from 20% to 18%. Since August 2012, serum ferritin and TSAT levels have been generally stable, DOPPS reported.
The increase in iron use corresponds with a well-documented decrease in hemoglobins and Epogen dosing. Mean hgb among all patients in the DOPPS sampling declined from 11.5 g/dL in August 2010 to 10.9 g/dL in March 2012. Mean hgb levels have remained relatively unchanged from early 2012 through April 2013. Among patients treated with an ESA, the percent with hgb >12 g/dL declined substantially since 2011, from 26% to 8%, while the percent with hgb <10 g/dL increased from 9% to 19%. In data from April 2013, 4%-5% of patients had hgb levels of < 9 g/dL.
High doses disappearing
Since August 2010, the size of the prescribed IV epoetin dose has decreased 31%; based on the April 2013 data, the mean dose is now 14,000 units/week in April 2013. High doses showed the greatest decline: doses >50,000 units/week declined from 11% to < 3% of prescriptions. Over the same time, the average administered IV epoetin dose has decreased 40% to 11,800 units/week. (The decline is greater than for prescribed dose because doses are now withheld more frequently, DOPPS said.) The median administered IV epoetin dose was 6,800 units/week in April 2013.
For the first time, average hgb levels are lower in the United States than in Europe, Canada, and Australia/New Zealand, the DOPPS researchers reported.
Jump in PTH levels
Serum PTH levels also increased 28% from August 2010 to April 2011, but have been largely stable since, DOPPS reported. In April 2013, the prevalence of very high PTH values (defined by DOPPS as PTH > 600 pg/mL) was 23% among black hemodialysis patients and 17% among non-black hemodialysis patients. While there has been no clear change in overall use of mineral and bone disorder medications, the DOPPS survey of U.S. dialysis clinic medical directors indicates a shift to a higher upper target for PTH management. Median serum calcium levels have now risen slightly (by 0.1 mg/dL), while serum phosphorus has remained generally constant.
Other DOPPS data from April shows:
– Among those on hemodialysis for more than a year, the percent of patients with URR > 65% increased from 91% to 95%, and the percent of patients with single pool Kt/V >1.2 increased from 93% to 95%.
– A modest increase in average hemodialysis session length, from 217 min/session in August 2010 to 221 min/session in April 2013, was reported. Correspondingly, the percent of patients with hemodialysis session length <210 min/session has declined, from 34% to 28%.
For the complete data reported at the Sept. 5 Web Ex, go to the Dialysis Practice Monitor website at www.dopps.org/DPM/