Dialysis Unplugged: Anemia and blood transfusion rates

So here is a commentary about a commentary.  Dan Weiner and Wolfgang Winkelmayer have an article in the latest issue of AJKD examining an AJKD paper that from DOPPS that reports US anemia data.

Weiner and Winkelmayer evaluate the results from Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor (DPM) data. This survey was established to look at pre- and post-bundle changes in dialysis practices and the impact of these changes on patients. They write:

“In the latest DPM update, [the authors report that], while the median hemoglobin level declined by 0.09 g/dL total over 11 months from August 2010 to July 2011, it declined in August 2011 by another 0.13 g/dL to 11.21 g/dL. The percentage of patients with hemoglobin levels greater than 12 g/dL declined from 32% to 28% from August 2010 through June 2011, and declined sharply over the next 2 months to 23%. There was a corresponding reduction in total ESA administered, seemingly reflecting the introduction of stopping rules at many dialysis providers. There was also far greater variability in practices across providers than seen in 2010 and early 2011, likely reflecting early versus late adoption of the new QIP cutpoints and new algorithms discouraging ESA use. Importantly, even with these changes, the proportions of patients with hemoglobin levels below 10 g/dL (∼10%) and below 9 g/dL (∼3%) remain fairly low.”

Weiner and Winkelmayer recommend that red blood cell transfusion rates should be monitored and perhaps the “the need for red blood cell transfusions (adjusted for case mix and indication) would be a useful quality measure”, implying that the reason that so few excursions of Hb concentrations below 10 g/dL have been observed is that patient’s are being aggressively transfused.

My take on this is that it would be great to monitor blood transfusion rates, but I think you will find that they haven’t changed that much. Facilities were perversely incentivized to use high dosages of ESA and paid little attention to Hb concentration, except keeping the Hb above 10 g/dL. What would be important at this point is to push education around blood transfusion, especially the new AABB guidelines that I have reviewed here a few weeks back. These indicate that there really is very little justification for transfusing a patient at 10 g/dL or even in most patients at 9 g/dL. 

On the other hand, rather than focusing on anemia, lets develop some quality measures around quality of life, functional capacity, cardiovascular complication rates and mortality. Isn’t that what should matter to patients?