Understanding the Recent Increase in Ferritin Levels in United States Dialysis Patients: Potential Impact of Changes in Intravenous Iron and Erythropoiesis-Stimulating Agent Dosing.
OBJECTIVE
Anemia management changed substantially among dialysis patients in the United States around the time of implementation of the new Centers for Medicare & Medicaid Services bundled payment system and erythropoiesis-stimulating agent (ESA) label change in 2011. Among these, average ferritin levels increased dramatically and have remained high since; this study sought to gain understanding of this sustained rise in ferritin levels.


METHODS
Trends in mean ferritin, hemoglobin, IV iron dose, and ESA dose from 2009 to 2013 were examined in 9735 patients from 91 United States Dialysis Outcomes and Practice Patterns Study facilities. Linear mixed models were used to assess the extent to which intravenous (IV) iron and ESA dose accounted for patients' changes in ferritin over time.


RESULTS
Mean ESA dose and hemoglobin levels declined throughout the study. Mean IV iron dose increased from 210 mg/mo in 2009-2010 to a peak of 280 mg/mo in 2011, then declined back to 200 mg/mo and remained stable from 2012 to 2013. Mean ferritin increased from 601 ng/ml in the third quarter of 2009 to 887 ng/ml in the first quarter of 2012; models suggest that higher IV iron dosing was a primary determinant during 2011, but lower ESA doses contributed to the sustained high ferritin levels thereafter. In a subset of 17 facilities that decreased IV iron dose in 2011, mean ferritin rose by 120 ng/ml to 764 ng/ml, which appeared to be primarily due to ESA reduction. Together, changes in IV iron and ESA doses accounted for 46% of the increase in ferritin over the study period.


CONCLUSIONS
In contrast to expectations, the rise in average IV iron dose did not persist beyond 2011. The sustained rise in ferritin levels in United States dialysis patients after policy changes in 2011, to average levels well in excess of 800 ng/ml, appeared to be partly due to reductions in ESA dosing and not solely IV iron dosing practices. The effect of these changes in ferritin on health outcomes requires further investigation.
Arbor Research Collaborative for Health, Ann Arbor, Michigan; Angelo.Karaboyas@ArborResearch.org.
Angelo
A
Karaboyas
Arbor Research Collaborative for Health, Ann Arbor, Michigan;
Jarcy
J
Zee
Arbor Research Collaborative for Health, Ann Arbor, Michigan; Departments of Epidemiology and Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, Michigan; Department of Urology and.
Hal
H
Morgenstern
Vifor Pharma, Glattbrugg, Switzerland;
Jacqueline G
JG
Nolen
Vanderbilt University, Nashville, Tennessee;
Raymond
R
Hakim
University of California-Irvine, Irvine, California; and.
Kamyar
K
Kalantar-Zadeh
University of New Mexico, Albuquerque, New Mexico.
Philip
P
Zager
Arbor Research Collaborative for Health, Ann Arbor, Michigan;
Ronald L
RL
Pisoni
Arbor Research Collaborative for Health, Ann Arbor, Michigan;
Friedrich K
FK
Port
Arbor Research Collaborative for Health, Ann Arbor, Michigan; Department of Internal Medicine, Medical School, University of Michigan, Ann Arbor, Michigan;
Bruce M
BM
Robinson
D061605:Administration, Intravenous; D000368:Aged; D000740:Anemia / Q000097:blood* / Q000188:drug therapy*; D004348:Drug Labeling; D005260:Female; D005293:Ferritins / Q000097:blood*; D006291:Health Policy; D006397:Hematinics / Q000008:administration & dosage*; D006454:Hemoglobins / Q000378:metabolism; D006801:Humans; D007501:Iron / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D064872:Patient Care Bundles; D011446:Prospective Studies; D006435:Renal Dialysis; D014481:United States
D006397:Hematinics; D006454:Hemoglobins; D005293:Ferritins; D007501:Iron
anemia; chronic kidney disease; dialysis; epoetin; erythropoietin