Red blood cell transfusion use in patients with chronic kidney disease (original) (raw)

Journal Article

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1

Ascentiant International

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Carlsbad, CA 92009

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USA

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2

Department of Epidemiology

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University of Alabama, Birmingham

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Birmingham, AB

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USA

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3

Division of Nephrology

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Stanford University School of Medicine

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Palo Alto, CA

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USA

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4

Amgen, Inc., Clinical Development

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Thousand Oaks, CA

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USA

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5

Department of Medicine

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University of Maryland

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Baltimore, MD

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USA

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6

Chronic Disease Research Group

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Minneapolis, MN

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USA

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4

Amgen, Inc., Clinical Development

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Thousand Oaks, CA

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USA

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Department of Epidemiology

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University of California, Los Angeles

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Los Angeles, CA

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USA

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Accepted:

20 November 2012

Published:

06 February 2013

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Karminder S. Gill, Paul Muntner, Richard A. Lafayette, Jeffrey Petersen, Jeffrey C. Fink, David T. Gilbertson, Brian D. Bradbury, Red blood cell transfusion use in patients with chronic kidney disease, Nephrology Dialysis Transplantation, Volume 28, Issue 6, June 2013, Pages 1504–1515, https://doi.org/10.1093/ndt/gfs580
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Abstract

Background

There is limited data available on the use of red blood cell (RBC) transfusions in younger chronic kidney disease patients not on dialysis (CKD-ND), for whom the consequences of developing antibodies to foreign antigens (allosensitization) may be particularly relevant.

Methods

We used the Ingenix medical claims database, comprising data on ∼40 million commercially insured US individuals, to identify annual (2002–08) cohorts of patients 18–64 years of age with newly diagnosed CKD. We followed each cohort for 1 year to estimate RBC transfusion rates and used Cox proportional hazards regression to identify patient characteristics associated with time to first transfusion.

Results

We identified 120 790 newly diagnosed CKD patients for the years 2002–08; 54% were 50–64 years of age. Overall, the transfusion rate was 2.64/100 person-years (PYs) (95% CI: 2.52–2.77). Rates were higher among those with diagnosed anemia [9.80/100 PYs (95% CI: 9.31–10.3)] and among those who progressed to end-stage renal disease (ESRD) [28.0/100 PYs (95% CI: 23.7–33.0)]. For those progressing to ESRD, transfusion rates more than doubled between 2002 and 2008. Of the factors evaluated, transfusion history and the presence of heart failure and diabetes were most strongly associated with a receipt of a transfusion.

Conclusions

RBC transfusions are relatively common and on the rise among younger CKD-ND patients who are anemic and progress to ESRD. Efforts to decrease the use of transfusions may be important for potential transplant candidates who progress to ESRD.

© The Author 2013. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

Topic:

• anemia
• kidney failure, chronic
• blood transfusion
• erythrocyte transfusion
• transfusion

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Comments

2 Comments

Re:Chronic Kidney Disease Patients Should Take Nephrologist Care At the Onset of the Disease

7 April 2013

Brian D. Bradbury (with Karminder S. Gill(1), Paul Muntner(2), Richard A. Lafayette(3), Jeffrey Petersen(4), Jeffrey C. Fink(5), Dave T. Gilbertson(6), Brian D. Bradbury(4,7))

Director, Observational Research, (1)Ascentiant International, Carlsbad, CA 92009, USA; (2)Department of Epidemiology, University of A

We thank Sarlak and colleagues for their thoughtful comments on our paper(1). We agree that anemia is a classic consequence of decreased renal function, its prevalence increases as kidney function declines and the availability of therapeutic interventions to treat the disease have helped to reduce the use of RBC transfusions(2), which have potential risks in this patient population(3). The authors point out that our finding of a mean outpatient Hb of 10.4 g/dL preceding a transfusion event is notably higher than the mean inpatient Hb of 8.8 g/dL (assessed within 2 days of the transfusion using EMR data) recently reported by Fox and colleagues(4), and they attribute this disparity to overtreatment. It is important to recognize that our estimate of 10.4 g/dL represents an outpatient value drawn up to 3 months preceding the transfusion event and does not reflect the hemoglobin triggering the administration of blood. As such, the mean Hb we report may be more useful for physicians to help them identify patients whose anemia may be progressively worsening and may require therapeutic intervention to avoid future RBC transfusions.

The authors also point out that individuals who received an ESA during the baseline period were more likely to receive a transfusion during up to one year of follow-up. The benefit of transfusion reduction with ESA therapy was established in the context of chronic therapy(5), but in our study we did not distinguish between chronic or episodic ESA treatment. In addition, use of an ESA may simply be a marker of disease severity (i.e. the patient required therapeutic intervention at some point in the past due to underlying disease); the adjusted analyses provide support for this explanation since in the final models, after all comorbidities and other markers of disease severity are included, prior/baseline ESA use is no longer predictive of receiving a transfusion.

Lastly, although the focus of our study was to examine the use of RBC transfusions over time, we agree with the authors that further evaluation of the risks of cardiovascular events and death in the CKD population would provide valuable information for the nephrology community.

References

1. Sarlak H, Demirkol S, Balta S, et al. Chronic Kidney Disease Patients Should Take Nephrologist Care At the Onset of the Disease. Nephrol. Dial. Transplant. 2013; 0:000.

2. Ibrahim HN, Ishani A, Guo H, Gilbertson DT. Blood transfusion use in non-dialysis-dependent chronic kidney disease patients aged 65 years and older. Nephrol Dial Transplant 2009;24:3138-43.

3. Ibrahim HN, Skeans MA, Li Q, Ishani A, Snyder JJ. Blood transfusions in kidney transplant candidates are common and associated with adverse outcomes. Clin Transpl 2011;25:653-9.

4. Fox KM, Yee J, Cong Z, et al. Transfusion burden in non-dialysis chronic kidney disease patients with persistent anemia treated in routine clinical practice: a retrospective observational study. BMC Nephrol 2012, 13:5

5. Amgen Inc. (2012). "Prescribing Information for Epogen (epoetin alfa), Supplement Number 5281, Approved May 2012." Retrieved June 21, 2012, from http://www.accessdata.fda.gov/drugsatfda\_docs/label/2012/103234s5281lbl.pdf.

Conflict of Interest:

The authors would like to disclose the following potential conflicts of interest: KG has a consultancy with Amgen; PM has received honoraria, research support, and has a consultancy with Amgen; RL has a consultancy with Fibrogen, Inc.; JP works for Clinical Development at Amgen; JF has a consultancy with Amgen and Sandoz; DG has a consultancy and has received honoraria from Amgen; BB works for the Center of Observational Research at Amgen.

Submitted on 07/04/2013 8:00 PM GMT

Chronic Kidney Disease Patients Should Take Nephrologist Care At the Onset of the Disease

31 March 2013

Hakan sarlak (with Sait Demirkol, Sevket Balta, Mustafa Cakar, Muharrem Akhan, Omer Kurt)

Internal medicine, gulhane medical faculty

Dear Editor, we read the article "Red blood cell transfusion use in patients with chronic kidney disease" written by Karminder S. Gill et al. with great interest [1]. They concluded that red blood cell (RBC) transfusions occured in younger patients with chronic kidney disease (CKD) at much higher rates among those with more advanced CKD and who were anemic [1]. Also, a sizeable proportion would be preventable and awareness that patients with a history of transfusion, and hemoglobin concentrations 10 g/dl and/or with advanced disease were at higher trasfusion risk would help prompt therapeutic interventions in place of transfusion [1]. Anemia is a classic consequence of reduced renal function, and its prevalence is almost universal by the time CKD progresses to end-stage renal disease (ESRD) [2]. The introduction of erythropoiesis stimulating agents (ESAs) has improved the quality of life for CKD patients, including those on dialysis [2]. In the study by Kathleen M Fox et al., it was concluded that blood transfusions were prevalent among non-dialysis (ND)-CKD patients with persistent anemia; and 20% of patients were transfused. The mean hemoglobin level closest and prior to transfusion was around 9 g/dl and an average of 2 units of blood was transfused per transfusion [3]. In the present study, the mean hemoglobin concentration of patients who were transfused was 10.4 g/dl. We think that this is an overtreatment. We see that patients who recieved an ESA during the baseline period had a higher incidence of transfusions during the follow-up period [1]. We believe it is important to take chronic ESA therapy and nephrologist care to decrease the rates of transfusions [4]. In addition, the patients should receive nephrologist care when they are diagnosed as ?CKD (eGFR<60 ml/min) to prevent high rates of transfusions [5]. In the current study, we think that it would have been more powerful if the long-term follow-up had been made in terms of outcomes like cardiovascular events or mortality. References Karminder S. Gill, Paul Muntner, Richard A. Lafayette, Jeffrey Petersen, Jeffrey C. Fink, David T. Gilbertson, Brian D. Bradbury. Red blood cell transfusion use in patients with chronic kidney disease. Nephrol Dial Transplant?(2013) 1-9. Ibrahim HN, Ishani A, Guo H, Gilbertson DT. Blood transfusion use in non-dialysis-dependent chronic kidney disease patients aged 65 years and older. Nephrol Dial Transplant?2009; 24: 3138-3143. Kathlen M Fox, Jerry Yee, Ze Cong et al. Transfusion burden in non-dialysis chronic kidney disease patients with persistent anemia treated in routine clinical practice: a retrospective observational study. Nephrology?2012, 13:5. Lawler EV, Gagnon DR, Fink J et al. Initiation of anaemia management in patients with chronic kidney disease not on dialysis in the Veterans Health Administration. Nephrol Dial Transplant?2010; 25: 2237-2244. Aalten J, Bemelman FJ, van den Berg- Loonen EM et al. Pre-kidney-transplant blood transfusions do not improve transplantation outcome: a Dutch national study. Nephrol Dial Transplant 2009; 24: 2559-2566.

Conflict of Interest:

None declared

Submitted on 31/03/2013 8:00 PM GMT

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