Successful creation of an anemia management algorithm for hemodialysis patients

Figures & data

Figure 1 The flow of patients.

Abbreviations: ESA, erythropoiesis-stimulating agent; CERA, continuous erythropoietin receptor activator.

Figure 2 Blood test schedule.

Notes: ^†1. During an intermediate blood test, the hemoglobin (Hb) change for 0.5 month (δHb) was evaluated. ^†2. During a regular blood test, if the erythropoiesis-stimulating agent dose was not changed at the last intermediate blood test, the Hb change for 1 month (ΔHb) was evaluated. ^†3. During a regular blood test, if the erythropoiesis-stimulating agent dose was changed at the last intermediate blood test, the Hb change for 0.5 month (δHb) was evaluated.

Figure 3 Iron algorithm.

Notes: This algorithm was used only at regular blood tests. If ferritin was not measured during a month, the last ferritin result was used. ^§Do not administer iron this month.
Abbreviations: Hb, hemoglobin (g/dL); ΔHb: Hb changes for 1 month (g/dL): ESA, erythropoiesis-stimulating agent.

Figure 4 First flow chart of erythropoiesis-stimulating agent (ESA) algorithm.

Figure 5 Chart number 1: The erythropoiesis-stimulating agent dose had not been changed for the last 3 months. Each chart (Chart nos 1–6; Figures 5–10) was more sensitive to hemoglobin (Hb) decreases than to Hb increases except when the Hb value was high, because other than deficiency of erythropoiesis-stimulating agent doses and iron, there may have been myriad causes that led to decreases in Hb values.

Figure 6 Chart number 2: The erythropoiesis-stimulating agent dose was increased or decreased 0.5 month ago. This chart was used to monitor hemoglobin (Hb) changes at the 0.5-month mark and was created for monitoring short-term Hb increases or decreases.

Figure 7 Chart number 3: The erythropoiesis-stimulating agent (ESA) dose was increased 1 month ago. Compared with Chart number 1 (Figure 5), this chart was more sensitive to hemoglobin (Hb) decreases when the Hb value was ≥9 g/dL and more permissive to Hb increases when Hb values ranged from ≥9 to <11.5 g/dL, because the Hb value may increase partially because of an increase in ESA; however, our ESA algorithm could watch for unexpected Hb decreases.

Figure 8 Chart number 4: The erythropoiesis-stimulating agent (ESA) dose was increased 1.5–3 months ago. Compared with Chart number 3 (Figure 7), this chart was more sensitive to hemoglobin (Hb) decreases when Hb values ranged from ≥9 to <11 g/dL because the Hb value should increase fully because of an increase in ESA. Our ESA algorithm could watch for unexpected Hb decreases.

Figure 9 Chart number 5: The erythropoiesis-stimulating agent (ESA) dose was decreased 1–3 months ago. Compared with Chart number 1 (Figure 5), this chart was more sensitive to hemoglobin (Hb) increases when Hb values ranged from ≥11 to <12 g/dL, more sensitive to Hb decreases when Hb values ranged from ≥9 to <11 g/dL, and more permissive to Hb decreases when Hb values ranged from ≥11.5 to <12 g/dL, because the Hb value should decrease because of a decrease in ESA. Our ESA algorithm could watch for unexpected Hb increases and excessive Hb decreases.

Figure 10 Chart number 6: Intermediate blood tests. This chart was used to monitor hemoglobin (Hb) changes at the 0.5-month mark and was created for monitoring short-term Hb increases or decreases.

Figure 11 Decision table.

Notes: “Iron received” meant that one course of iron is/was administered. “No iron” meant that iron is/was not administered.
Abbreviation: ESA, erythropoiesis-stimulating agent.

Figure 12 Erythropoiesis-stimulating agent dose adjustment worksheet.

Note: =, interchangeable.

Table 1 Baseline characteristics

	n=49
Age (years)	67.1±10.4
Female (n)	24
Diabetes mellitus (n)	19
Duration of HD (months)	124±105

Note: Age and duration of HD are presented as mean ± standard deviation.

Abbreviation: HD, hemodialysis.

Figure 13 Trend in mean hemoglobin values ± standard deviation at regular blood tests.

Figure 14 Percentage of patients in the target hemoglobin (Hb) range of 10–12 g/dL and the trend in the Hb standard deviation at regular blood tests.

Table 2 Comparisons between baseline data (0 month) and data at the end of our study (6 months)

	0 month (n=49)	6 months (n=49)	P-value
Hemoglobin (g/dL)	11±1	10.9±0.7	0.682
ESA dose (IU/week)a	7,133±6,107	7,592±7,759	0.357
Cardiothoracic ratio (%)	50.4±5.2	49.8±5.3	0.226
Dry weight (kg)	54±11.3	53.6±11.4	0.181
Albumin (g/dL)	3.6±0.4	3.6±0.3	0.325
TSAT (%)	21.5±7.3	20.6±7	0.409
Ferritin (ng/mL)	50.7±39.2	37.4±27.2	0.011

Notes: Data are presented as mean ± standard deviation.

a Doses of darbepoetin alpha were converted to doses of epoetin beta according to the conversion ratio of 225:1.

Abbreviations: ESA, erythropoiesis-stimulating agent; TSAT, transferrin saturation rate.