Original Investigation: Dialysis Therapy
Anemia management and outcomes from 12 countries in the dialysis outcomes and practice patterns study (DOPPS)

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Abstract

Background:Anemia is common in hemodialysis (HD) patients. Methods:Data collected from nationally representative samples of HD patients (n = 11,041) in 2002 to 2003 were used to describe current anemia management for long-term HD patients at 309 dialysis units in 12 countries. Analyses of associations and outcomes were adjusted for demographics, 15 comorbid classes, laboratory values, country, and facility clustering. Results:For patients on dialysis therapy for longer than 180 days, 23% to 77% had a hemoglobin (Hgb) concentration less than 11 g/dL (<110 g/L), depending on country; 83% to 94% were administered erythropoietin (EPO). Mean Hgb levels were 12 g/dL (120 g/L) in Sweden; 11.6 to 11.7 g/dL (116 to 117 g/L) in the United States, Spain, Belgium, and Canada; 11.1 to 11.5 g/dL (111 to 115 g/L) in Australia/New Zealand, Germany, Italy, the United Kingdom, and France; and 10.1 g/dL (101 g/L) in Japan. Hgb levels were substantially lower for new patients with end-stage renal disease, and EPO use before ESRD ranged from 27% (United States) to 65% (Sweden). By patient, EPO use significantly declined with greater Hgb concentration (adjusted odds ratio, 0.61 per 1-g/dL [10-g/L] greater Hgb level; P < 0.0001), as did EPO dosage. Case-mix-adjusted mortality and hospitalization risk declined by 5% and 6% per 1-g/dL greater patient baseline Hgb level (P ≤ 0.003 each), respectively. Furthermore, patient mortality and hospitalization risks were 10% to 12% lower for every 1-g/dL greater facility mean Hgb level. Patients were significantly more likely to have Hgb levels of 11 g/dL or greater (≥110 g/L) if they were older; were men; had polycystic kidney disease; had greater albumin, transferrin saturation, or calcium levels; were not dialyzing with a catheter; or had lower ferritin levels. Facilities with greater intravenous iron use showed significantly greater facility mean Hgb concentrations. Mean EPO dose varied from 5,297 (Japan) to 17,360 U/wk (United States). Greater country mean EPO doses were significantly associated with greater country mean Hgb concentrations. Several patient characteristics were associated with greater EPO doses. Even in some countries with high intravenous iron use, 35% to 40% of patients had a transferrin saturation less than 20% (below guidelines). Conclusion:These findings indicate large international variations in anemia management, with significant improvements during the last 5 years, although many patients remain below current anemia guidelines, suggesting large and specific opportunities for improvement.

Section snippets

Data sources

Anemia management was assessed by using data from both DOPPS I (data collection, 1996 to 2001) and DOPPS II (data collection, 2002 to present). The DOPPS is a prospective observational study involving adult HD patients randomly selected from 308 representative dialysis facilities in 7 countries (France, Germany, Italy, Japan, Spain, the United Kingdom, and the United States) for DOPPS I and 309 representative dialysis facilities in 12 countries (Australia, Belgium, Canada, France, Germany,

Relationship of patient Hgb concentrations with mortality and hospitalization risks

In Cox models, relative risks (RRs) for mortality and all-cause hospitalization were 5% and 6% lower, respectively, for every 1-g/dL (10-g/L) greater Hgb concentration when using baseline Hgb level of each patient as a continuous variable and adjusting for a large number of patient demographic and comorbidity characteristics (RR, 0.95 and 0.94, respectively; P ≤ 0.003 each). As shown in Fig 1, the relationship with both mortality and hospitalization risk varied across categories of Hgb

Discussion

These current results from the international DOPPS indicate large improvements in anemia management during the last several years, with HD populations in more than half the DOPPS countries showing a mean Hgb level of 11.5 g/dL or greater (≥115 g/L). Recently, Locatelli et al5 showed significant increases in HD patients’ Hgb levels in 5 European countries within 1 year after publication of the EBPG on anemia management.19 These guidelines, along with the NKF-K/DOQI guidelines first published in

Acknowledgements

The authors gratefully acknowledge helpful suggestions from Dr Naoki Kimata; the assistance of Trinh Pifer, Justin Albert, Miles P. Finley, Caroline Shevrin, and Stacey Elder with preparation of this manuscript; the work of David Dickinson, Jon Bodfish, and Rameswari Metla in maintaining the DOPPS database; the multitude of activities of Michael Losey, Theresa Helm, and Patrick Carlson in working with the sites participating in the DOPPS; and the great dedication of staff members and medical

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    The Dialysis Outcomes and Practice Patterns Study is supported by research grants from Amgen Inc and Kirin Brewery Ltd without restrictions on publications.

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