L HEATH1, C CHOW1, L SPENCER1, E O’LONE1,2
1Royal North Shore Hospital, St Leonards, Australia, 2The University of Sydney, Sydney, Australia
Aim: To evaluate haematinics, haemoglobin and erythropoietin-stimulating agent (ESA) dosing before and after the implementation of a proactive iron protocol in patients undergoing maintenance haemodialysis.
Background: The PIVOTAL trial demonstrated that among patients undergoing maintenance haemodialysis, a high-dose, proactive intravenous iron regimen resulted in reduced ESA dosing and fewer cardiovascular events, with equivalent safety data. This prompted the revision of our local iron protocol.
Methods: Data was collected over two three-month periods, before and 6 months after the introduction of the proactive iron protocol in all patients on maintenance haemodialysis in our satellite and in-centre units. Demographics, iron and ESA dosing, haemoglobin levels, iron indices and C-reactive protein (CRP) were recorded. We assessed differences between groups using a t test or Wilcoxon rank-sum test depending on parametric or nonparametric data for continuous variables, and the chi-squared test for categorical variables.
Results: The total cohort consisted of 96 patients. Using the proactive iron protocol, median ESA doses were 270mcg of darbepoetin alpha (interquartile range (IQR) [25th to 75th percentile] 130-495) and 240mcg of methoxy polyethylene glycol-epoetin beta (IQR 120-375), compared with previous median doses of 360mcg (IQR 180-720; p=0.001) and 300mcg (interquartile range 200-400; p=0.001), respectively. The median cumulative iron dose under the proactive protocol was 400mcg (IQR 200-600) compared with 300mcg previously (IQR 0-600; p=0.015). Mean haemoglobin levels did not change significantly (113.4g/L vs. 114.8g/L, p=0.54), but ferritin levels increased (mean 516mcg/L vs. 551mcg/L, p=0.03), with no change in mean CRP (14.7mg/L vs. 17.4mg/L, p=0.29).
Conclusion: The implementation of a proactive iron protocol resulted in reduced usage of ESA, despite no significant increase in iron dosing.
Dr Lauren Heath is a final year Basic Physician Trainee based at Royal North Shore Hospital in Sydney, NSW. She graduated from The University of Sydney with a combined degree in Medicine and Arts, with first class honours. Lauren is keen to pursue advanced training in nephrology, with a particular interest in general nephrology and preventative renal medicine.