« Back

Discontinuation of EPO better than dose reduction among patients on dialysis who exceed hemoglobin targets, study data suggest

Monday, November 12 2007 | Comments

---

What's This? Discontinuation of erythropoietin (EPO), rather than dose reduction, may be appropriate in patients whose most recent hemoglobin exceeds 13 g/dL, study data suggest.

"Responding to potential risks associated with hemoglobin variability, the Centers for Medicare & Medicaid Services implemented a new EPO Monitoring Policy on April 3, 2006, allowing continued EPO dosing at Hb levels >=13 g/dL, and mandating a 25% reduction in total erythropoiesis-stimulating agent dose for patients exceeding this level," the authors of the study wrote.

Researchers evaluated the effects of a change in dosing algorithm implemented in response to this policy in which EPO dosages were reduced instead of temporarily discontinued among patients with Hb levels >=13 g/dL. This algorithm was applied to 1,688 individuals who received hemodialysis at any of 18 hemodialysis units from December 2005 to April 2006. All units switched to the reduction protocol on May 1, 2006.

During the 14-month study period (total of 15,695 patient-months), the mean Hb level was 11.8 g/dL among patients on the discontinuation protocol compared with a mean Hb level of 11.9 g/dL among those on the reduction protocol (P<.0001).

Further, the number of patients with Hb levels from 11 g/dL to 11.9 g/dL and 12 g/dL to 12.9 g/dL was significantly greater among those on the discontinuation protocol than among those on the reduction protocol (P=.004 and P<.0001, respectively). In contrast, the number of patients with Hb levels >=13 g/dL was significantly greater among those on the reduction protocol than among those on the discontinuation protocol (P<.0001).

The median EPO dose per treatment among patients on the discontinuation protocol was 3,219 units compared with a median EPO dose of 3,477 among those on the reduction protocol (P<.0001). Additionally, EPO use among patients on the reduction protocol was significantly greater than among patients on the discontinuation protocol in the month that preceded Hb levels of 12 g/dL to 12.9 g/dL and >=13 g/dL (P<.001 and P<.0001, respectively).

There was no significant between-protocol difference in the proportion of patients whose Hb levels fell to 10 g/dL to 10.9 g/dL or <10 g/dL, the authors noted.

"The 2006 Kidney Disease Outcomes Quality Initiative anemia management guidelines and CMS reimbursement policy were motivated in large part by concern about Hb variability and therefore focus on avoidance of low Hb levels," the authors wrote. "[T]his study supports more aggressive reduction in EPO administration in response to high Hb levels than is currently required by CMS reimbursement guidelines."

These findings were published online Oct. 31 ahead of print by the Journal of the American Society of Nephrology by Weiner DE, et al.

Print  |  E-mail