NN&I - April 2010
Patient Management www.nephronline.comApril 2010 Nephrology News & Issues 33 scheme will be fully phased in by 2014. The result will turn overuse of ESAs into a financial liability for hemodi -alysis facilities rather than a financial advantage and force facilities to search for more cost-effective means of com-plying with clinical performance mea -sures for hemodialysis patients, includ -ing the use of IV iron and the greater use of subcutaneous ESA dosing.42 Since DRIVE, several other studies have looked at the issue of high serum ferritin levels and reducing ESAs with IV iron dosing regimens. Coyne and colleagues administered a 500 to 1000-mg loading dose of IV ferric gluconate to patients on hemodialysis who were receiving \03718,000 U/week of ESAs, had serum ferritin levels <1500 ng/mL and TSAT levels <30%, and had not received a loading dose of IV iron in the previous 6 months. Twelve weeks after IV iron administration, the mean Hb increased from 10.5 to 11.7 g/dL and the mean TSAT increased from 21.9% to 29%. The patients' ESA requirements decreased by more than 45% during this period from a mean of 12,245 to 6,694 units per hemodialysis session. There were no significant alterations in serum fer -ritin levels.43Lower ESA doses and higher serum ferritin levels were both associated with increased survival in one of the few studies that has looked directly at the correlation between IV iron use, Hb level, and survival. A total of 1,774 patients on maintenance hemodialysis at three centers were treated in this study from January 1998 to June 2007. Patients were followed until death or study termination.15 Over the duration of the study, both the mean Hb (11.4 g/ dL) and TSAT levels (30.6%) were main-tained within KDOQI-recommended ranges.1,9 As seen in Figure 3A, survival was lowest in those receiving the high-est weekly ESA doses (>27,740 units per week) and highest in those receiving the lowest weekly doses (\03612,100 units per week). In contrast, survival was lowest in those receiving no IV iron and best in those receiving a relatively low monthly dose (1 mg to 202 mg per month). Low and medium (202 mg to 455 mg per month) monthly doses of IV iron both had a powerful independent positive effect on survival. There was no inde-pendent survival benefit for ESA use in patients who did not receive IV iron.15The mean serum ferritin level over the course of the study was approxi- mately 594 ng/mL. As could be expect -ed, survival was poor for those with serum ferritin levels <100 ng/mL. Importantly, there was little difference Figure 3B. Estimated proportion of maintenance hemodialysis patients surviving, stratifed by serum ferritin level. Reprinted with permission from Pollack, 2009. 15 Survival T ime (Days)Serum FerritinProportion of Patients SurvivingFigure 3B500600 - 1000 \265g/L 100 - 300 \265g/L >1000 \265g/L 300 - 600 \265g/L \037100 \265g/L1000 1500 0 2000 2500 1.00 .75 .25 .50 0 Patient Management_0410_8.indd 33 3/19/10 2:54:23 PM
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