Shift in Anemia Management in CKD Patients Identified

Use of ESAs declined while use of blood transfusions increased between 2008 and 2012.
Use of ESAs declined while use of blood transfusions increased between 2008 and 2012.

CHICAGO—Management of anemia in Medicare patients with non-dialysis-dependent chronic kidney disease (NDD-CKD) shifted between 2008 and 2012, new study findings suggest.

In 2008, the most common anemia treatment was erythropoiesis-stimulating agents (ESAs); in 2012, it was red blood cell (RBC) transfusion.

The change occurred after publication of the results of the Trial to Reduce Cardiovascular Events with Aranesp Therapy (TREAT) in 2009, FDA labeling revisions for ESAs in 2011, and the release of new Kidney Disease: Improving Global Outcomes (KDIGO) anemia treatment guidelines in 2012. TREAT was a double-blind, placebo-controlled trial involving 4038 patients with CKD, diabetes, and anemia randomized to receive darbepoetin alfa or placebo. The trial, the results of which were published in the New England Journal of Medicine (2009;361:2019-2032), was conducted at 623 sites in 24 countries.

A team led by Wendy L. St. Peter, PharmD, of the University of Minnesota and Chronic Disease Research Group in Minneapolis, used the 20% Medicare database to identify 2 cohorts of NDD-CKD patients aged 66 – 85 years with stage 3–5 CKD and anemia: a 2008 cohort (71,744 patients) and a 2012 cohort (109,251 patients).

In the 2008 cohort, 29.4% of patients received ESAs; 21.3% received RBC transfusions; and 6.3% received intravenous (IV) iron, the researchers reported at the American Society of Nephrology's 2016 Kidney Week meeting. In the 2012 cohort, 12.7% of patients received ESAs, 22% received RBC transfusions, and 6.7% received IV iron. In addition, in 2008, 9.7% of patients received consistent ESA treatment compared with 3.4% in 2012. Dr St. Peter's group defined consistent ESA treatment as 1 or more monthly administrations of ESAs in at least 80% of 12 follow-up months.

From 2008 to 2012, the median time to treatment initiation from anemia diagnosis increased from 11 to 18 days for ESAs, decreased from 59 to 34 days for RBC transfusion, and remained stable for IV iron (87 days in 2008, 84 days in 2012).

“ESA use plummeted in older Medicare-covered NDD-CKD patients with anemia in the timeframe following publication of TREAT trial results in 2009 and ESA label changes in 2011,” Dr St. Peter told Renal & Urology News. “These events seem to have triggered healthcare practitioners to use RBC transfusions sooner. In addition, more stage 5 NDD-CKD patients received RBC transfusions in the 2012 versus 2008 patient group, which is concerning from the perspective of increased potential for increased panel reactive antibodies and greater wait times for future kidney transplantation.”

The study was sponsored by AstraZeneca and FibroGen.

Reference

1. St. Peter WL, Guo H, Kabadi S, et al. Anemia treatment pattern changes in non-dialysis-dependent chronic kidney disease patients before and after revised Food and Drug Administration label and anemia guidelines for erythropoiesis-stimulating agents. Presented at the American Society of Nephrology's 2016 Kidney Week meeting in Chicago, November 16–20. Poster FR-PO767

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