Anemia management and outcomes from 12 countries in the dialysis outcomes and practice patterns study (DOPPS)


      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.


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        • US Renal Data System
        USRDS Annual Data Report, treatment modalities.
        Am J Kidney Dis. 1994; 24: S57-S75
        • Locatelli F
        • Conte F
        • Marcelli D
        The impact of haematocrit levels and erythropoietin treatment on overall and cardiovascular mortality and morbidity—The experience of the Lombardy Dialysis Registry.
        Nephrol Dial Transplant. 1998; 13: 1642-1644
        • Ma J.Z
        • Ebben J
        • Xia H
        • Collins A.J
        Hematocrit level and associated mortality in hemodialysis patients.
        J Am Soc Nephrol. 1999; 10: 610-619
        • Xia H
        • Ebben J
        • Ma J.Z
        • Collins A.J
        Hematocrit levels and hospitalization risks in hemodialysis patients.
        J Am Soc Nephrol. 1999; 10: 1309-1316
        • Locatelli F
        • Pisoni R.L
        • Combe C
        • et al.
        Anaemia in haemodialysis patients in five European countries.
        Nephrol Dial Transplant. 2004; 19: 121-132
        • Renal Association
        Treatment of Adults and Children With Renal Failure. (ed 3). Royal College of Physicians of London and the Renal Association, London, UK2002
        • Foley R.N
        • Parfrey P.S
        • Harnett J.D
        • Kent G.M
        • Murray D.C
        • Barre P.E
        The impact of anemia on cardiomyopathy, morbidity, and mortality in end stage renal disease.
        Am J Kidney Dis. 1998; 31: 53-61
        • Levin A
        • Thompson C.R
        • Ethier J
        • et al.
        Left ventricular mass index increase in early renal disease.
        Am J Kidney Dis. 1999; 34: 125-134
        • O'Riordan E
        • Foley R.N
        Effects of anaemia on cardiovascular status.
        Nephrol Dial Transplant. 2000; 15: S19-S22
        • Nissenson A.R
        Epoetin and cognitive function.
        Am J Kidney Dis. 1992; 20: S21-S24
        • Beusterien K.M
        • Nissenson A.R
        • Port F.K
        • Kelly M
        • Steinwald B
        • Ware Jr, J.E
        The effects of recombinant human erythropoietin on functional health and well-being in chronic dialysis patients.
        J Am Soc Nephrol. 1996; 7: 763-773
        • Canadian Erythropoietin Study Group
        Association between recombinant human erythropoietin and quality of life and exercise capacity of patients receiving hemodialysis.
        BMJ. 1990; 3: 573-578
        • Evans R.W
        • Rader B
        • Manninen D.L
        • Cooperative Multicenter EPO Clinical Trial Group
        The quality of life of hemodialysis recipients treated with recombinant human erythropoietin.
        JAMA. 1990; 263: 825-830
        • Lundin A.P
        • Akerman M.J
        • Chesler R.M
        • et al.
        Exercise in hemodialysis patients after treatment with recombinant human erythropoietin.
        Nephron. 1991; 58: 315-319
        • McMahon L.P
        • McKenna M.J
        • Sangkabutra T
        • et al.
        Physical performance and associated electrolyte changes after haemoglobin normalization.
        Nephrol Dial Transplant. 1999; 14: 1182-1187
        • Moreno F
        • Sanz-Guajardo D
        • Lopez-Gomez J.M
        • Jofre R
        • Valderrabano F
        Increasing the hematocrit has a beneficial effect on quality of life and is safe in selected hemodialysis patients. Spanish Cooperative Renal Patients Quality of Life Study Group of the Spanish Society of Nephrology.
        J Am Soc Nephrol. 2001; 11: 335-342
        • Painter P
        • Moore G
        • Carlson L
        • et al.
        Effects of exercise training plus normalization of hematocrit on exercise capacity and health-related quality of life.
        Am J Kidney Dis. 2002; 39: 257-265
        • National Kidney Foundation
        K/DOQI Clinical Practice Guidelines.
        Am J Kidney Dis. 2001; 37: S1-S238
      1. European Best Practice Guidelines for the management of anaemia in patients with chronic renal failure.
        Nephrol Dial Transplant. 1999; 14: S1-S50
        • Toffelmire E.B
        • Barrett B.J
        • Fenton S.S
        • et al.
        Clinical practice guidelines for the management of anemia coexistent with chronic renal failure.
        J Am Soc Nephrol. 1999; 10: S292-S296
        • Lacson Jr, E
        • Ofsthun N
        • Lazarus J.M
        Effect of variability in anemia management on hemoglobin outcomes in ESRD.
        Am J Kidney Dis. 2003; 41: 111-124
        • Berns J.S
        • Elzein H
        • Lynn R.I
        • Fishbane S
        • Meisels I.S
        • Deoreo P.B
        Hemoglobin variability in epoetin-treated hemodialysis patients.
        Kidney Int. 2003; 64: 1514-1521
        • Greenwood R.N
        • Ronco C
        • Gastaldon F
        • et al.
        Erythropoietin dose variation in different facilities in different countries and its relationship to drug resistance.
        Kidney Int Suppl. 2003; 87: S78-S86
        • Young E.W
        • Goodkin D.A
        • Mapes D.L
        • et al.
        The Dialysis Outcomes and Practice Patterns Study.
        Kidney Int Suppl. 2000; 74: S74-S81
        • Klein J
        • Moeschberger M
        Survival Analysis Techniques for Censored and Truncated Data. Springer, New York, NY1997: 416-418
        • Snyder J.J
        • Foley R.N
        • Gilbertson D.T
        • Vonesh E.F
        • Collins A.J
        Hemoglobin levels and erythropoietin doses in hemodialysis and peritoneal dialysis patients in the United States.
        J Am Soc Nephrol. 2004; 15: 174-179
        • SAS Institute Inc
        SAS/STAT User's Guide. vol 2. SAS Institute Inc, Cary, NC2000: 1452 (Version 8)
        • Ofsthun N
        • Labrecque J
        • Lacson E
        • Keen M
        • Lazarus J.M
        The effects of higher hemoglobin levels on mortality and hospitalization in hemodialysis patients.
        Kidney Int. 2003; 63: 1908-1914
        • Clyne N
        • Jogestrand T
        Effect of erythropoietin treatment on physical exercise capacity and on renal function in predialytic uremic patients.
        Nephron. 1992; 60: 390-396
        • Foley R.N
        • Parfrey P.S
        • Morgan J
        • et al.
        Effect of hemoglobin levels in hemodialysis patients with asymptomatic cardiomyopathy.
        Kidney Int. 2000; 58: 1325-1335
        • Hampl H
        • Sternberg C
        • Berweck S
        • et al.
        Regression of left ventricular hypertrophy in hemodialysis patients is possible.
        Clin Nephrol. 2002; 58: S73-S96
        • Silverberg D.S
        • Wexler D
        • Blum M
        • et al.
        The effect of correction of anaemia in diabetics and non-diabetics with severe resistant congestive heart failure and chronic renal failure by subcutaneous erythropoietin and intravenous iron.
        Nephrol Dial Transplant. 2003; 18: 141-146
        • Xue J.L
        • St Peter W.L
        • Ebben J.P
        • Everson S.E
        • Collins A.J
        Anemia treatment in the pre-ESRD period and associated mortality in elderly patients.
        Am J Kidney Dis. 2002; 40: 1153-1161
        • Valderrabano F
        • Horl W.H
        • Macdougall I.C
        • Rossert J
        • Rutkowski B
        • Wauters J.P
        Pre-dialysis survey on anaemia management.
        Nephrol Dial Transplant. 2003; 18: 89-100
        • Collins A.J
        Anaemia management prior to dialysis.
        Nephrol Dial Transplant. 2003; 18: S2-S6
        • Furuland H
        • Linde T
        • Ahlmen J
        • Christensson A
        • Strombom U
        • Danielson B.G
        A randomized controlled trial of haemoglobin normalization with epoetin alfa in pre-dialysis and dialysis patients.
        Nephrol Dial Transplant. 2003; 18: 353-361
        • Walters B.A
        • Hays R.D
        • Spritzer K.L
        • Fridman M
        • Carter W.B
        Health-related quality of life, depressive symptoms, anemia, and malnutrition at hemodialysis initiation.
        Am J Kidney Dis. 2002; 40: 1185-1194
        • Owen Jr, W.F
        Patterns of care for patients with chronic kidney disease in the United States.
        J Am Soc Nephrol. 2003; 14: S76-S80
        • Reddan D.N
        • Frankenfield D.L
        • Klassen P.S
        • et al.
        Regional variability in anaemia management and haemoglobin in the US.
        Nephrol Dial Transplant. 2003; 18: 147-152
        • Combe C.h
        • Pisoni R.L
        • Port F.K
        • et al.
        Dialysis Outcomes and Practice Patterns Study.
        Nephrologie. 2001; 22: 379-384
        • Pisoni R.L
        • Young E.W
        • Combe C
        • et al.
        Higher catheter use within facilities is associated with increased mortality and hospitalization.
        J Am Soc Nephrol. 2001; 12 (abstr): 299A
        • Nassar G.M
        • Fishbane S
        • Ayus J.C
        Occult infection of old nonfunctioning arteriovenous grafts.
        Kidney Int Suppl. 2002; 80: S49-S54
        • Ministry of Health and Welfare
        Revised Point Fee System for Social Insurance. Shakai-hoken Kenkyujo, Tokyo, Japan2002 (in Japanese)
        • Canaud B
        • Bennhold I
        • Delons S
        • et al.
        What is the optimum frequency of administration of r-HuEPO for correcting anemia in hemodialysis patients?.
        Dial Transplant. 1995; 24: 306-329
        • Derose S.F
        • Diesto J.T
        • Crooks P.W
        Sustainability of subcutaneous erythropoietin dosing.
        J Am Soc Nephrol. 2001; 12 (abstr): 325A
        • Jensen J.D
        • Madsen J.K
        • Jensen L.W
        Comparison of dose requirement, serum erythropoietin and blood pressure following intravenous and subcutaneous erythropoietin treatment of dialysis patients.
        Eur J Clin Pharmacol. 1996; 50: 171-177
        • Kaufman J
        • Reda D.J
        • Fye C.L
        • et al.
        Subcutaneous compared with intravenous epoetin in patients receiving hemodialysis.
        N Engl J Med. 1998; 339: 578-583
        • Parker K.P
        • Mitch W.E
        • Stivelman J.C
        • et al.
        Safety and efficacy of low-dose subcutaneous dosing of epoetin alfa in hemodialysis patients.
        J Am Soc Nephrol. 1997; 8: 288-293
        • Stockenhuber F
        • Liobl U
        • Jahn C
        • et al.
        Intravenous versus subcutaneous application of erythropoietin in patients on RDT and CAPD. Meeting of the American Society of Nephrology.
        Kidney Int. 1990; 37 (abstr): 379A
        • Moist L
        • House A
        • Wazny L
        • Muirhead N
        Switching from SC to IV EPO.
        J Am Soc Nephrol. 2003; 14 (abstr): 265A
        • Goodkin D.A
        • Bragg-Gresham J.L
        • Koenig K.G
        • et al.
        Association of comorbid conditions and mortality in hemodialysis patients in Europe, Japan, and the United States.
        J Am Soc Nephrol. 2003; 14: 3270-3277
        • Pisoni R.L
        • Young E.W
        • Dykstra D.M
        • et al.
        Vascular access use in Europe and the United States.
        Kidney Int. 2002; 61: 305-316
        • Rayner H.C
        • Pisoni R.L
        • Bommer J
        • et al.
        Mortality and hospitalization in haemodialysis patients in five European countries.
        Nephrol Dial Transplant. 2004; 19: 108-120