Analysis of Anemia Management Protocol in Home Dialysis

Background: Anemia is a common complication of chronic kidney disease with multiple possible etiologies and management options. Given the prevalence of anemia within patients on dialysis, diagnosis and management can be burdensome with a significant impact to quality of care. To provide safe and effective care for patients on dialysis, many in-center dialysis units utilize nursing protocols for managing anemia with success. The objective was to assess the effectiveness of a similar protocol for home dialysis patients. Methods: An anemia management protocol outlining decisions for identifying home dialysis patients with anemia and assessing for need of intravenous iron repletion and/or erythrocyte stimulating agents (ESA) was implemented on 5/1/2022. Patient data were assessed for effects on hemoglobin, ferritin, and transferrin saturation (TSAT) before and after the date of implementation. ESA drugs were mailed from a central pharmacy and iron was repletion was given either at home or at an infusion center for peritoneal dialysis (PD). Results: A cohort of 133 home dialysis patients, encompassing both PD and home hemodialysis (HHD), was analyzed from 5/1/2022 to 5/31/2023. The median hemoglobin levels were 10.5 g/dL (IQR: 9.7-11.3) prior to protocol implementation and 10.5 g/dL (IQR: 9.7-11.5) post-implementation; p-value 0.56. Median ferritin levels increased from 405 ng/mL (IQR: 237-610) pre-implementation to 424 ng/mL (IQR: 263-737) post-implementation; p-value 0.19. Median transferrin saturation (TSAT) rose from 28% (IQR: 20.5-36) to 30% (IQR: 24-38); p-value 0.11. Among patients receiving erythropoiesis-stimulating agents (ESAs), the incidence of hemoglobin values exceeding 12 g/dL decreased from 28 cases pre-implementation to 12 cases post-implementation. Conclusion: Overall, it appears that implementation of anemia management protocol was at least as effective as solely provider directed management. There was a trend toward fewer episodes of Hb > 12 mg/dL which could represent lower exposure to ESAs. Other potential benefits of such a protocol include reduced provider burden and reduced unit cost and improved patient safety with lower ESA exposure and fewer blood transfusions; however, further analysis and studies are needed to elucidate statistically significant results and other impacts, including implementation of newer agents such as hypoxia-inducible factor prolyl hydroxylase Inhibitors.