title: Association of a change in erythropoiesis-stimulating agent dose during hospitalization and subsequent hemoglobin levels and transfusions in hemodialysis patients.
abstract: BACKGROUND
  Erythropoiesis-stimulating agent (ESA) doses are often increased in hospitalized dialysis patients in response to acute anemia with unknown consequences. We sought to determine whether increases in ESA dose during hospital admission were associated with changes in transfusion requirement and risk of exceeding recommended hemoglobin targets.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Linked administrative, laboratory, and blood transfusion data were used to identify a total of 700 hospitalizations involving 484 long-term hemodialysis patients between 2004 and 2008 in the Calgary Health Region, Canada.
  
  
  METHODS
  Change in ESA dose was determined by comparing the average weekly dose over the 6 weeks preceding admission to that administered during the 14 days following admission.
  
  
  METHODS
  Cox proportional hazards models adjusted for baseline patient characteristics were used to model the association between changes in ESA dose and outcomes, including exceeding recommended hemoglobin targets, receipt of blood transfusion, cardiovascular outcomes, and death.
  
  
  RESULTS
  There was a significant increase in the risk of exceeding recommended hemoglobin targets as the ESA dose was increased by ≥40 μg/wk (equivalent darbepoetin alfa dose) above baseline (HR, 2.21; 95% CI, 1.19-4.10). However, an increase in ESA dose was not associated with reduced need for blood transfusion, risk of cardiovascular outcomes, or death.
  
  
  CONCLUSIONS
  Residual confounding by clinical events that may lead to changes in the management of patients and may have influenced the observed relationship between predictor and outcomes.
  
  
  CONCLUSIONS
  Increasing the ESA dose at hospitalization in hemodialysis patients is associated with higher risk of exceeding recommended hemoglobin targets, but does not appear to be associated with the need for transfusion, risk of cardiovascular outcomes, or death.
authors.affiliation: University of Calgary, Calgary, Canada.
authors.forename: Ben C
authors.initials: BC
authors.lastname: Wong
authors.forename: Pietro
authors.initials: P
authors.lastname: Ravani
authors.forename: Braden J
authors.initials: BJ
authors.lastname: Manns
authors.forename: Adriane
authors.initials: A
authors.lastname: Lewin
authors.forename: Xin
authors.initials: X
authors.lastname: Zhang
authors.forename: Rick
authors.initials: R
authors.lastname: Chin
authors.forename: Brenda R
authors.initials: BR
authors.lastname: Hemmelgarn
authors.forename: Marcello
authors.initials: M
authors.lastname: Tonelli
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Oliver
authors.forename: Robert R
authors.initials: RR
authors.lastname: Quinn
mesh_terms: D000368:Aged; D000740:Anemia / Q000209:etiology / Q000628:therapy*; D001803:Blood Transfusion; D002318:Cardiovascular Diseases / Q000453:epidemiology; D015331:Cohort Studies; D019468:Disease Management; D004305:Dose-Response Relationship, Drug; D005260:Female; D006397:Hematinics / Q000627:therapeutic use*; D006454:Hemoglobins / Q000378:metabolism*; D006801:Humans; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D006435:Renal Dialysis / Q000009:adverse effects*; D051436:Renal Insufficiency, Chronic / Q000097:blood / Q000628:therapy*; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D006397:Hematinics; D006454:Hemoglobins
keywords: Erythropoietin stimulating agents; hemodialysis; hospitalization; transfusion