Comparative Effectiveness of Iron and Erythropoiesis-Stimulating Agent Dosing on Health-Related Quality of Life in Patients Receiving Hemodialysis.
BACKGROUND
The potential effects of iron-dosing strategies and erythropoiesis-stimulating agents (ESAs) on health-related quality of life (HRQoL) in the dialysis population are unclear. We examined the independent associations of bolus versus maintenance iron dosing and high versus low ESA dosing on HRQoL.


METHODS
Retrospective cohort design.


METHODS
Clinical data (2008-2010) from a large dialysis organization merged with data from the US Renal Data System. 13,039 patients receiving center-based hemodialysis were included.


METHODS
Iron and ESA dosing were assessed during 1-month (n=14,901) and 2-week (n=15,296) exposure periods.


RESULTS
HRQoL was measured by the Kidney Disease Quality of Life (KDQOL) instrument (0-100 scale) during a 3-month follow-up period.


METHODS
Generalized linear mixed models, adjusting for several covariates, were used to estimate associations between iron and ESA dosing and HRQoL overall and for clinically relevant subgroups.


RESULTS
For the 1-month exposure period, patients with lower baseline hemoglobin levels who received higher ESA dosing had higher physical health and kidney disease symptom scores (by 2.4 [95% CI, 0.6-4.2] and 5.6 [95% CI, 2.8-8.4] points, respectively) in follow-up than patients who received lower ESA dosing. For the 2-week exposure period, patients with low baseline hemoglobin levels who received bolus dosing had higher mental health scores (by 1.9 [95% CI, 0.0-3.8] points) in follow-up. Within the low-baseline-hemoglobin subgroup, individuals with a catheter or dialysis vintage less than 1 year who received higher ESA dosing had higher HRQoL scores in follow-up (by 5.0-9.9 points) and individuals with low baseline transferrin saturations who received bolus dosing had higher HRQoL scores in follow-up (by 2.6-5.8 points).


CONCLUSIONS
Observational design; short duration of observation.


CONCLUSIONS
For individuals with low baseline hemoglobin levels, higher ESA dosing and bolus iron dosing were associated with slightly higher HRQoL scores in follow-up. These differences became more pronounced and clinically relevant for specific subgroups.
Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC. Electronic address: janet_freburger@unc.edu.
Janet K
JK
Freburger
Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Alan R
AR
Ellis
Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Lily
L
Wang
Department of Epidemiology, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Anne M
AM
Butler
Kidney Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Abhijit V
AV
Kshirsagar
Section of Nephrology, Baylor College of Medicine, Houston, TX.
Wolfgang C
WC
Winkelmayer
Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Epidemiology, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.
M Alan
MA
Brookhart
D000328:Adult; D000368:Aged; D015331:Cohort Studies; D004305:Dose-Response Relationship, Drug; D004920:Erythropoiesis / Q000187:drug effects* / Q000502:physiology; D005260:Female; D005500:Follow-Up Studies; D006304:Health Status; D006397:Hematinics / Q000008:administration & dosage*; D006801:Humans; D007501:Iron / Q000008:administration & dosage*; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000628:therapy; D008297:Male; D008875:Middle Aged; D011788:Quality of Life; D006435:Renal Dialysis / Q000009:adverse effects* / Q000379:methods; D012189:Retrospective Studies; D016896:Treatment Outcome
D006397:Hematinics; D007501:Iron
Health-related quality of life (HRQoL); anemia; bolus dosing; chronic kidney disease (CKD); dosing pattern; end-stage renal disease (ESRD); epoetin alfa; erythropoiesis-stimulating agent (ESA); hemodialysis (HD); hemoglobin; intravenous iron; maintenance dosing; transferrin saturation (TSAT)