ATLANTA—Recent changes in anemia management in the U.S. hemodialysis population, such as reduced use of erythopoiesis-stimulating agents (ESAs) and increased use of intravenous (IV) iron, have not occurred in Europe or Japan, suggesting a big impact of reimbursement or regulatory changes in the U.S., investigators concluded in a study presented at the American Society of Nephrology’s Kidney Week 2013.

In January 2011, the federal government rolled out a new prospective payment system in which dialysis centers are paid a flat rate for dialysis services (“bundling”). Later that year, changes were made to ESA labeling and a Quality Incentive Program update removed the 10 g/dL lower hemoglobin (Hb) target.

Douglas S. Fuller, MD, of Arbor Research Collaborative Health in Ann Arbor, Mich., and colleagues used data from the Dialysis Outcomes and Practice Patterns Study to examine ESA-managed hemoglobin (Hb), serum ferritin, and ESA and IV iron use in the U.S., Europe, and Japan from August 2010 to December 2012.

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In August 2010, mean ESA-management Hb in the U.S. was 11.3 g/dL, similar to that in Europe. This diverged after the June 2011 ESA label change, the researchers found. By December 2012, mean ESA-managed Hb was 10.7, 10.7, and 11.1 g/dL in the U.S., Japan, and Europe. ESA use any time over three months changed from 95% to 89% in the U.S., 91% to 89% in Europe, and 87% to 91% in Japan.

The median prescribed intravenous (IV) epoetin dose fell 41% in the U.S. to 102 U/wk/kg in December 2012 compared with minimal change in Europe and Japan. Monthly IV iron use during the study period rose from 55% to 68% in the U.S. but remained stable in Europe and Japan. Mean ferritin rose 35% to 825 ng/mL in the U.S., 8% in Europe, and no increase in Japan. Dr. Fuller’s group noted that higher ferritin values in the U.S. may be due to higher mean IV iron doses there compared with other countries.

The researchers pointed out that mean Hb levels are lower in the U.S. than in Europe for the first time in more than 10 years.