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Original Investigation |

Trends in Anemia Care in Older Patients Approaching End-Stage Renal Disease in the United States (1995-2010)

Wolfgang C. Winkelmayer, MD, ScD1,2; Aya A. Mitani, MPH3; Benjamin A. Goldstein, PhD3; M. Alan Brookhart, PhD4; Glenn M. Chertow, MD, MPH1,2
[+] Author Affiliations
1Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
2Department for Health Research and Policy, Stanford University School of Medicine, Palo Alto, California
3Division of General Medical Disciplines, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
4Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
JAMA Intern Med. 2014;174(5):699-707. doi:10.1001/jamainternmed.2014.87.
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Importance  Anemia is common in patients with advanced chronic kidney disease. Whereas the treatment of anemia in patients with end-stage renal disease (ESRD) has attracted considerable attention, relatively little is known about patterns and trends in the anemia care received by patients before they start maintenance dialysis or undergo preemptive kidney transplantation.

Objective  To determine the trends in anemia treatment received by Medicare beneficiaries approaching ESRD.

Design, Setting, and Participants  Closed cohort study in the United States using national ESRD registry data (US Renal Data System) of patients 67 years or older who initiated maintenance dialysis or underwent preemptive kidney transplantation between 1995 and 2010. All eligible patients had uninterrupted Medicare (A+B) coverage for at least 2 years before ESRD.

Exposure  Time, defined as calendar year of incident ESRD.

Main Outcomes and Measures  Use of erythropoiesis-stimulating agents (ESA), intravenous iron supplements, and blood transfusions in the 2 years prior to ESRD; hemoglobin concentration at the time of ESRD. We used multivariable modified Poisson regression to estimate utilization prevalence ratios (PRs).

Results  Records of 466 803 patients were analyzed. The proportion of patients with incident ESRD receiving any ESA in the 2 years before increased from 3.2% in 1995 to a peak of 40.8% in 2007; thereafter, ESA use decreased modestly to 35.0% in 2010 (compared with 1995; PR, 9.85 [95% CI, 9.04-10.74]). Among patients who received an ESA, median time from first recorded ESA use to ESRD increased from 120 days in 1995 to 337 days in 2010. Intravenous iron administration increased from 1.2% (1995) to 12.3% (2010; PR, 9.20 [95% CI, 7.97-10.61]). The proportion of patients receiving any blood transfusions increased monotonically from 20.6% (1995) to 40.3% (2010; PR, 1.88 [95% CI, 1.82-1.95]). Mean hemoglobin concentrations were 9.5 g/dL in 1995, increased to a peak of 10.3 g/dL in 2006, and then decreased moderately to 9.9 g/dL in 2010.

Conclusions and Relevance  Between 1995 and 2010, older adults approaching ESRD were increasingly more likely to be treated with ESAs and to receive intravenous iron supplementation, but also more likely to receive blood transfusions.

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Figure 1.
Trends in Treatment With Erythropoiesis-Stimulating Agents (ESAs) Prior to End-Stage Renal Disease (ESRD)

A, Proportion of patients having received treatment with an ESA. B, Time from first recorded treatment with an ESA to ESRD (in days). Circles indicate median; error bars, interquartile range. C, Adjusted prevalence ratios of ESA use prior to ESRD (referent: 1995). Multivariable model adjusted for age, sex, race, Medicaid (“dual”) eligibility, comorbid diabetes mellitus, estimated glomerular filtration rate, and body mass index at ESRD. Circles indicate prevalence ratio; error bars, 95% confidence interval.

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Figure 2.
Trends in Treatment With Intravenous Iron Supplements Prior to End-Stage Renal Disease (ESRD)

A, Proportion of patients receiving any intravenous iron supplementation. B, Specific intravenous iron formulation used in the earliest available claim. C, Adjusted prevalence ratios of intravenous iron use prior to ESRD (referent: 1995). Multivariable model adjusted for age, sex, race, Medicaid (“dual”) eligibility, comorbid diabetes mellitus, estimated glomerular filtration rate, and body mass index at ESRD. Circles indicate prevalence ratio; error bars, 95% confidence interval.

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Figure 3.
Trends in Blood Transfusion Use Prior to End-Stage Renal Disease (ESRD)

A, Proportion of patients receiving any blood transfusion. B, Number of blood transfusion days. Compared with 2003 through 2006, the trend lines for transfusion use and number of transfusion days accelerated significantly in the period 2007 through 2010 (P < .001 and P = .04, respectively). C, Adjusted prevalence ratios of any blood transfusion prior to ESRD (referent: 1995). Multivariable model adjusted for age, sex, race, Medicaid (“dual”) eligibility, comorbid diabetes mellitus, estimated glomerular filtration rate, and body mass index at ESRD. Circles indicate prevalence ratio; error bars, 95% confidence interval.

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Figure 4.
Venn Diagrams of Use Among Anemia Treatments Prior to End-Stage Renal Disease (ESRD), 2010

Numbers in circles correspond to percentage of patients who received the corresponding anemia treatment(s) in the 2 years prior to reaching ESRD. The number in the bottom right corner indicates the percentage of patients who did not receive any of the 3 treatments. ESA indicates erythropoiesis-stimulating agent.

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Figure 5.
Hemoglobin Concentration at Start of Therapy for End-Stage Renal Disease (ESRD)

Circles indicate mean; error bars, 95% confidence interval.

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