Ari H Pollack1,2, Assaf P Oron3, Joseph T Flynn4,5, Raj Munshi4,5. 1. Division of Nephrology, Seattle Children's Hospital, Seattle, WA, USA. ari.pollack@seattlechildrens.org. 2. Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA. ari.pollack@seattlechildrens.org. 3. Section of Epidemiology, Institute for Disease Modeling, Bellevue, WA, USA. 4. Division of Nephrology, Seattle Children's Hospital, Seattle, WA, USA. 5. Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.
Abstract
BACKGROUND: Erythropoietin-stimulating agent hyporesponsiveness (ESAH) is associated with increased cardiovascular mortality in patients with end-stage renal disease (ESRD) on hemodialysis. Dynamic treatment regimes (DTR), a clinical decision support (CDS) tool that guides the prescription of specific therapies in response to variations in patient states, have been used to guide treatment for chronic illnesses that require frequent monitoring and therapy changes. Our objective is to explore the role of utilizing a DTR to reduce ESAH in pediatric hemodialysis patients. METHODS: Retrospective analysis of ESRD patients on hemodialysis who received ESAs. Dosing was adjusted using a locally developed protocol designed to target a hemoglobin between 10 and 12 g/dl. Analyzing this protocol as a DTR, we assessed adherence to the protocol over time measuring how the hyporesponse index (ESA dose/hemoglobin value) changed due to varying levels of adherence. RESULTS: Eighteen patients met study criteria. Median hemoglobin was 11.4 g/dl (range 6.1-15.4), and median weekly ESA dose (darbepoetin-equivalent) was 0.4 mcg/kg/dose (range 0-2.1). Full adherence to the DTR was identified in 266 (71%) of the 4-week periods, with a median average adherence score of 0.80 (range 0.63-0.91). As adherence to the DTR improved, ESAH decreased. During the last 12 weeks, 13 out of 18 patients had lower average ESA/hemoglobin ratio than the first 12 weeks. CONCLUSIONS: A DTR appears to be well-suited to the treatment of anemia in ESRD and reduces ESAH. Our work shows the potential of DTRs to drive the development and evaluation of clinical practice guidelines.
BACKGROUND:Erythropoietin-stimulating agent hyporesponsiveness (ESAH) is associated with increased cardiovascular mortality in patients with end-stage renal disease (ESRD) on hemodialysis. Dynamic treatment regimes (DTR), a clinical decision support (CDS) tool that guides the prescription of specific therapies in response to variations in patient states, have been used to guide treatment for chronic illnesses that require frequent monitoring and therapy changes. Our objective is to explore the role of utilizing a DTR to reduce ESAH in pediatric hemodialysispatients. METHODS: Retrospective analysis of ESRDpatients on hemodialysis who received ESAs. Dosing was adjusted using a locally developed protocol designed to target a hemoglobin between 10 and 12 g/dl. Analyzing this protocol as a DTR, we assessed adherence to the protocol over time measuring how the hyporesponse index (ESA dose/hemoglobin value) changed due to varying levels of adherence. RESULTS: Eighteen patients met study criteria. Median hemoglobin was 11.4 g/dl (range 6.1-15.4), and median weekly ESA dose (darbepoetin-equivalent) was 0.4 mcg/kg/dose (range 0-2.1). Full adherence to the DTR was identified in 266 (71%) of the 4-week periods, with a median average adherence score of 0.80 (range 0.63-0.91). As adherence to the DTR improved, ESAH decreased. During the last 12 weeks, 13 out of 18 patients had lower average ESA/hemoglobin ratio than the first 12 weeks. CONCLUSIONS: A DTR appears to be well-suited to the treatment of anemia in ESRD and reduces ESAH. Our work shows the potential of DTRs to drive the development and evaluation of clinical practice guidelines.
Authors: Dagmara Borzych-Duzalka; Yelda Bilginer; Il Soo Ha; Mustafa Bak; Lesley Rees; Francisco Cano; Reyner Loza Munarriz; Annabelle Chua; Silvia Pesle; Sevinc Emre; Agnieszka Urzykowska; Lily Quiroz; Javier Darío Ruscasso; Colin White; Lars Pape; Virginia Ramela; Nikoleta Printza; Andrea Vogel; Dafina Kuzmanovska; Eva Simkova; Dirk E Müller-Wiefel; Anja Sander; Bradley A Warady; Franz Schaefer Journal: J Am Soc Nephrol Date: 2013-03-07 Impact factor: 10.121
Authors: Lynda A Szczech; Huiman X Barnhart; Jula K Inrig; Donal N Reddan; Shelly Sapp; Robert M Califf; Uptal D Patel; Ajay K Singh Journal: Kidney Int Date: 2008-07-02 Impact factor: 10.612