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HEMATOLOGY

Management of Anemia in Erythropoietin-Resistant Hemodialysis Patients

at time of writing, Clinical Pharmacist, Pharmaceutical Sciences Clinical Services Unit, Vancouver General Hospital, Vancouver, British Columbia, Canada; now, Clinical Pharmacist, Department of Pharmacy, British Columbia Cancer Agency, Vancouver Centre, Vancouver

Karen F Shalansky, PharmD FCSHP

Pharmacotherapeutic Specialist, Pharmaceutical Sciences Clinical Services Unit, Vancouver General Hospital; Clinical Assistant Professor, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver

Jacek P Jastrzebski, MD FRCP (C)

Nephrologist, Department of Medicine, Vancouver General Hospital; Assistant Professor, Faculty of Medicine, University of British Columbia

Reprints: Karen F Shalansky PharmD FCSHP, Pharmaceutical Sciences Clinical Services Unit, Vancouver General Hospital, 855 W. 12th Ave., Vancouver, British Columbia V5Z 1M9, Canada, FAX 604/875-5267, kshalans{at}vanhosp.bc.ca

BACKGROUND: Human recombinant erythropoietin (rHuEPO) is administered to patients with end-stage renal disease for treatment of anemia.

OBJECTIVE: To assess the impact of a structured team approach to anemia management in rHuEPO-resistant hemodialysis patients.

METHODS: This was an 8-month prospective, open-label, quality-improvement initiative. Nineteen patients in a 160-bed hemodialysis unit receiving rHuEPO doses >300 units/kg/wk were defined as rHuEPO-resistant. Hemoglobin (Hb), iron indices, parathyroid hormone, folate, B₁₂, aluminum, and reticulocyte counts were determined at baseline. The former 3 parameters were followed every 6, 12, and 26 weeks, respectively. Vascular access flow was regularly assessed via ultrasonic dilution methodology. Target Hb was 12.0–13.5 g/dL. All factors potentially contributing to rHuEPO resistance were assessed and, if possible, treated every 6 weeks by a dedicated anemia team. Downward rHuEPO dosage adjustments of 12.5–25% to the closest 1000 units were considered if underlying causes of rHuEPO resistance could not be identified or reversed, or if the Hb rose beyond the target level.

RESULTS: Dysfunctional vascular access and iron deficiency were the predominant treatable factors associated with rHuEPO resistance. At 8 months, mean rHuEPO dosage decreased significantly from 469 to 319 units/kg/wk (p < 0.001) and mean Hb increased significantly from 10.6 to 11.6 g/dL (p = 0.023). Eight-month cost savings approximated $45 000 (CDN$).

CONCLUSIONS: A structured team approach to the management of rHuEPO-resistant patients was successful in significantly lowering rHuEPO dosage with improvement in serum Hb at a substantial cost savings.

Key Words: anemia, erythropoietin, resistance, hemodialysis

Published Online, October 15, 2003. www.theannals.com, DOI 10.1345/aph.1D103