Chapter 8: Management of Anaemia in Haemodialysis and Peritoneal Dialysis Patients

Transcription

1 Chapter 8: Management of Anaemia in Haemodialysis and Peritoneal Dialysis Patients Donald Richardson, Alex Hodsman, Dirk van Schalkwyk, Charlie Tomson and Graham Warwick Summary. 41% of UK patients commence RRT with an Hb <10.0 g/l. The mean Hb at commencement of RRT is 10.3 g/dl.. % of patients on dialysis in the UK have a Hb g/dl by 6 months after commencement of RRT.. The median Hb on haemodialysis in the UK is 11.8 g/dl with an IQR of g/dl. 86% of haemodialysis patients in the UK have a Hb g/dl. The median Hb on peritoneal dialysis in the UK is 12.0 g/dl with an IQR of g/dl. % of peritoneal dialysis patients in the UK have a Hb g/dl.. In the UK, 49% of patients on PD and 48% of patients on haemodialysis have a Hb between g/dl.. The median ferritin in UK haemodialysis patients is 413 mg/l (IQR ), % of UK haemodialysis patients have a ferritin 5 mg/l.. The median ferritin in UK PD patients is 256 mg/l (IQR ), 86% of UK peritoneal dialysis patients have a ferritin 5 mg/l.. A higher proportion of HD patients than PD patients receive ESA therapy (88% vs 76%). The ESA dose is higher for HD than PD patients (9204 vs IU/week). Introduction This chapter describes data reported to the Renal Registry relating to management of renal anaemia through The chapter reports outcomes of submitted variables and analyses of these variables in the context of established guidelines and recommendations. More recently introduced NICE guidelines are also quoted to place current outcomes into context with future expectations. Methods This chapter analyses the incident and prevalent RRT cohort for The Registry extracts quarterly data electronically from renal units in England, Wales and Northern Ireland and is sent data annually from the Scottish Renal Registry. Patients treated by dialysis during the last quarter of 2005 were included in the analysis if they had been on the same modality of dialysis in the same centre for 3 months. The last available measurement of haemoglobin and ferritin from each patient in the last two quarters of 2005 was used for analysis. For incident patients, data from their first quarter on dialysis was used. Patients who do not have this data are excluded from the analyses. Data from Northern Ireland and Scotland are included for the first time this year. Patients are analysed as a complete cohort and divided by modality into groups. Some analysis is also done on a combined dialysis group. The completeness of data items are analysed at unit and country level. All patients are included in analyses but units with less than % completeness are excluded from the caterpillar plots showing unit performance. Both at unit and country level, data are also excluded from plots when there are less than 20 patients with data. The number preceding the centre name in each figure indicates the percentage of missing data for that centre. The data are analysed to calculate summary statistics. These are maximum, minimum and average (mean and median) values. Standard deviation and quartile ranges are also calculated. These data are represented as caterpillar plots showing median values and quartile ranges. 115

2 The UK Renal Registry The Ninth Annual Report The percentage achieving Renal Association standards is also calculated for haemoglobin. The percentage of patients achieving serum ferritin 5 mg/l and 5200 mg/l have also been calculated. These are represented as caterpillar plots with % confidence intervals shown. For the percentage achieving standards 2 values have also been calculated to identify significant variability between centres and between nations. Longitudinal analysis has also been done to calculate overall changes in achievement of standards annually from 1998 to Haemoglobin The NSF part 1 1 and the Renal Association standards document 3rd edition 2 state that individuals with CKD should achieve a haemoglobin of 10 g/dl within 6 months of being seen by a nephrologist, unless there is a specific reason why it could not be achieved. The UK Renal Registry does not collect a specific haemoglobin value 6 months from meeting a nephrologist. Some indication of whether the standard is reached comes from the Hb at the start of renal replacement therapy. The Registry plans to collect pre-dialysis data for patients who then commence RRT. The European Best Practice Guidelines (EBPG) 3 set a minimum target of 11 g/dl for all patients and United States (KDOQI) 4 guidelines set a target haemoglobin range of g/dl. The NICE guidelines published in now recommend a target haemoglobin of between 10.5 and 12.5 g/dl (with ESA dose changes considered at 11 and 12 g/dl), perhaps recognising the difficulty of narrowing the distribution of haemoglobin to between g/dl. For this reason data are also presented in terms of the new NICE guidelines. However, it should be recognised that the data reported in this chapter were collected before the publication of the NICE guidelines. In light of the normalisation of haemoglobin study in haemodialysis patients 6 (Besarab et al., NEJM), and also now the results of the CREATE 7 and CHOIR 8 studies in CKD patients demonstrating similar outcomes regards increased mortality at higher target Hb, the new NICE desired outcome range g/dl may be very relevant to reduction in patient risk as well as the most cost effective use of resources. Haemoglobin of patients with CKD In patients new to dialysis, the starting haemoglobin currently gives the only indication we have of concordance with current anaemia management recommendations in the predialysis group. Patients not receiving dialysis (conservative care) are by definition excluded from the dataset. The Registry aims to collate data on a defined pre-dialysis/non-dialysis group in the future. The percentage of data returned and outcome haemoglobin are listed in Table 8.1. Analyses on Table 8.1: Haemoglobin levels for new patients starting haemodialysis or peritoneal dialysis % data return Median Hb g/dl % range Interquartile range %Hb 510 g/dl Abrdn Airdrie 44 n/a n/a n/a n/a Antrim B Heart B QEH Bangor Basldn Belfast Bradfd Brightn Bristol Camb Cardff Carlis Carsh Chelms

3 Chapter 8 Management of Anaemia in Haemodialysis and Peritoneal Dialysis Patients % data return Median Hb g/dl Table 8.1: (continued) % range Interquartile range %Hb 510 g/dl Clwyd Covnt D&Gall n/a n/a n/a n/a Derby Dorset Dudley Dundee Dunfn n/a n/a n/a n/a Edinb Exeter GlasRI GlasWI Glouc Hull Inverns n/a n/a n/a n/a Ipswi Klmarnk 78 n/a n/a n/a na L Barts 0 n/a n/a n/a n/a L Guys L H&CX L Kings L Rfree Leeds Leic Livrpl ManWst Middlbr Newc Newry 33 n/a n/a n/a n/a Norwch Nottm Oxford Plymth Ports Prestn Redng Sheff Shrew Stevng Sthend Sund Swanse Truro Tyrone Ulster 89 n/a n/a n/a n/a Wirral 2 n/a n/a n/a n/a Wolve Wrexm York Eng NI Sct Wls UK Note: Median Hb for units with less than 20 new patients or data returns <% are not shown 117

4 The UK Renal Registry The Ninth Annual Report Haemoglobin g/dl N = 4,374 Upper quartile Median Lower quartile 40 Antrim 2 Shrew 0 Carlis 8 Livrpl 24 Dundee 0 Leeds 0 Dorset 5 Newc 14 Clwyd 5 Carsh 1 Cardff 26 Brightn 0 Edinb 20 Camb 3 GlasWI 0 Bangor 0 Abrdn 0 Sund 18 L Guys 13 ManWst 0 Ipswi 14 Stevng 0 Basldn 0 Dudley 0 Redng 2 Bradfd 4 Wolve 1 Ports 1 Oxford 2 Norwch 0 Sheff 1 L H&CX 0 GlasRI 1 L Kings 30 Plymth 0 Truro 3 L Rfree 12 Belfast 7 Hull 6 Sthend 16 Derby 5 Tyrone 1 Nottm 15 Covnt 0 Glouc 1 Leic 17 B QEH 5 Prestn 1 Middlbr 4 B Heart 46 Wrexm 3 Chelms 0 Exeter 0 Swanse 11 Eng 24 NI 10 Sct 6 Wls 11 UK Figure 8.1: Haemoglobin median and interquartile range for incident patients Percentage with Hb 10 g/dl N = 4,374 Upper % Cl % with Hb 10 Lower % Cl Antrim 3 GlasWI 2 Shrew 14 Clwyd 14 Stevng 0 Bangor 8 Livrpl 0 Abrdn 1 Cardff 0 Ipswi 0 Edinb 0 Carlis 0 Truro 3 L Rfree 5 Carsh 0 GlasRI 1 Oxford 30 Plymth 0 Dorset 2 Norwch 26 Brightn 24 Dundee 0 Dudley 13 ManWst 20 Camb 1 L H&CX 0 Basldn 5 Newc 18 L Guys 0 Sund 6 Sthend 0 Leeds 4 Wolve 0 Redng 1 Ports 2 Bradfd 5 Tyrone 1 L Kings 15 Covnt 0 Glouc 0 Sheff 16 Derby 7 Hull 17 B QEH 12 Belfast 1 Leic 1 Nottm 4 B Heart 1 Middlbr 5 Prestn 0 Exeter 3 Chelms 46 Wrexm 0 Swanse 11 Eng 24 NI 10 Sct 6 Wls 11 UK Figure 8.2: Percentage of incident patients, by centre, achieving RA target unit returns with incomplete data sets are obviously open to criticism. Returns of <% are excluded from unit level analysis. It is unlikely, although possible, that exclusion of data from these units will alter the overall conclusions. The current starting median haemoglobin in the UK is 10.3 g/dl with 59% of patients starting dialysis with an Hb 510 g/dl. Thus 41% of patients commence dialysis therapy with an Hb <10.0 g/dl. There is a wide range of compliance with the audit standard of Hb 510 g/dl between units, from 38 88%. The wide range in starting Hb may reflect different practices in referral to nephrologists or differences in funding for predialysis ESA therapy. The median starting Hb is shown in Figure 8.1 and the percentage starting with an Hb g/dl by unit are given in Figure 8.2. The distribution of haemoglobin in incident patients by unit is shown in Figure 8.3. Figures 8.4 and 8.5 illustrate the improvement in correction of anaemia over the first year of haemodialysis in incident patients. Data on the haemoglobin prior to starting RRT and the relationship between this variable and comorbidity is presented in Chapter 6 9. Both these figures suggest that availability of and/or better utilisation of ESA products for 118

5 Chapter 8 Management of Anaemia in Haemodialysis and Peritoneal Dialysis Patients 11 UK 6 Wls 10 Sct 24 NI 11 Eng 0 Swanse 46 Wrexm 3 Chelms 0 Exeter 5 Prestn 1 Middlbr 4 B Heart 1 Nottm 1 Leic 12 Belfast 17 B QEH 7 Hull 16 Derby 0 Sheff 0 Glouc 15 Covnt 1 L Kings 5 Tyrone 2 Bradfd 1 Ports 0 Redng 4 Wolve 0 Leeds 6 Sthend 0 Sund 18 L Guys 5 Newc 0 Basldn 1 L H&CX 20 Camb 13 ManWst 0 Dudley 24 Dundee 26 Brightn 2 Norwch 0 Dorset 30 Plymth 1 Oxford 0 GlasRI 5 Carsh 3 L Rfree 0 Carlis 0 Truro 0 Edinb 0 Ipswi 1 Cardff 0 Abrdn 8 Livrpl 14 Stevng 0 Bangor 14 Clwyd 2 Shrew 3 GlasWI 40 Antrim < Percentage of patients Figure 8.3: Distribution of haemoglobin in incident dialysis patients 119

6 The UK Renal Registry The Ninth Annual Report Haemoglobin g/dl Upper quartile Median Lower quartile Start 3 mths 6 mths 12 mths Time Figure 8.4: Quarterly median haemoglobin for incident patients in 2005 Percentage of patients 55 Upper % CI % with Hb 10 Lower % CI Start 3 mths 6 mths 12 mths Time Figure 8.5: Quarterly percentage of incident patients with haemoglobin 510 g/dl in 2005 use in the dialysis population is much improved in recent times with % compliance by 6 months after commencement of dialysis. It is uncertain whether poor availability of ESA funding, reluctance to treat or late referral is responsible for the ongoing prevalence of relative anaemia in patients commencing RRT. Haemoglobin of prevalent haemodialysis patients The compliance with data returns and haemoglobin outcome for haemodialysis patients are shown in Table 8.2. The median haemoglobin for haemodialysis patients by unit and compliance with the minimum standard Hb 510 g/dl and the Hb 511 g/dl standard are shown in Figures 8.6, 8.7 and 8.8 respectively. The distribution of Hb in the haemodialysis population is shown, by unit, in Figure 8.9. The compliance with the new NICE guidelines for outcome haemoglobin g/dl is shown in Figure It should be noted that the dataset predates the NICE guidelines published in In Table 8.2 the inter-quartile range for the UK is 1.9 g/dl. Even at the ideal median Hb of 11.5 g/dl and a normal distribution for Table 8.2: Haemoglobin data for prevalent patients on haemodialysis % data return Median Hb g/dl % range Quartile range Mean Hb g/dl Standard deviation % with Hb 510 % with Hb 511 Abrdn Airdrie Antrim B Heart B QEH Bangor Basldn Belfast Bradfd Brightn Bristol Camb Cardff Carlis Carsh Chelms Clwyd Covnt D&Gall

7 Chapter 8 Management of Anaemia in Haemodialysis and Peritoneal Dialysis Patients % data return Median Hb g/dl % range Table 8.2: (continued) Quartile range Mean Hb g/dl Standard deviation % with Hb 510 % with Hb 511 Derby Dorset Dudley Dundee Dunfn Edinb Exeter GlasRI GlasWI Glouc Hull Inverns Ipswi Klmarnk L Barts 0 n/a n/a n/a n/a n/a n/a n/a L Guys L H&CX L Kings L Rfree Leeds Leic Livrpl ManWst Middlbr Newc Newry Norwch Nottm Oxford Plymth Ports Prestn Redng Sheff Shrew Stevng Sthend Sund Swanse Truro Tyrone Ulster Wirral 7 n/a n/a n/a n/a n/a n/a n/a Wolve Wrexm York Eng NI Sct Wls UK

8 The UK Renal Registry The Ninth Annual Report Haemoglobin g/dl Upper quartile Median N = 13,422 Lower quartile 0 Bradfd 0 Leeds 1 Glouc 2 Cardff 0 Wolve 0 Shrew 2 Livrpl 0 Ulster 0 Newc 2 Edinb 0 Norwch 7 Tyrone 8 Antrim 1 Ports 0 Airdrie 1 Klmarnk 4 Inverns 4 Newry 6 Clwyd 19 ManWst 1 L H&CX 1 Sheff 18 Wrexm 3 B QEH 1 Basldn 0 Derby 2 GlasWI 7 Belfast 1 Dorset 5 Dundee 1 Middlbr 2 Leic 3 Swanse 6 Bangor 1 Redng 2 Sund 12 Carsh 2 Hull 1 Oxford 2 Abrdn 2 Chelms 6 B Heart 2 GlasRI 0 Ipswi 3 Sthend 11 L Guys 1 Dunfn 3 Prestn 17 Stevng 31 Camb 0 L Kings 7 L Rfree 1 Exeter 7 Carlis 8 Plymth 16 Dudley 2 Covnt 1 Truro 0 Nottm 0 D&Gall 31 Brightn 10 Eng 6 NI 2 Sct 5 Wls 8 UK Figure 8.6: Median haemoglobin: HD Percentage of patients 55 Upper % Cl % with Hb 10 N = 13,422 Lower % Cl 8 Antrim 6 Clwyd 4 Newry 2 Edinb 0 Bradfd 0 Shrew 0 Leeds 0 Norwch 0 Wolve 7 Tyrone 0 Ulster 4 Inverns 2 Cardff 1 Sheff 1 Truro 3 Swanse 2 Livrpl 2 Leic 1 L H&CX 0 Newc 2 Abrdn 1 Dorset 0 Ipswi 1 Redng 1 Oxford 0 Nottm 0 Airdrie 12 Carsh 17 Stevng 7 Belfast 1 Middlbr 1 Glouc 5 Dundee 1 Klmarnk 1 Ports 3 Sthend 3 Prestn 2 Hull 2 Covnt 2 Chelms 6 Bangor 3 B QEH 2 GlasWI 1 Exeter 2 GlasRI 7 Carlis 1 Dunfn 7 L Rfree 2 Sund 19 ManWst 6 B Heart 1 Basldn 0 Derby 11 L Guys 0 L Kings 8 Plymth 18 Wrexm 31 Camb 0 D&Gall 16 Dudley 31 Brightn 10 Eng 6 NI 2 Sct 5 Wls 8 UK Figure 8.7: Percentage of HD patients with Hb 510 g/dl Percentage of patients N = 13,422 Upper % Cl % with Hb 11 Lower % Cl 8 Antrim 6 Clwyd 0 Bradfd 0 Ulster 0 Shrew 0 Leeds 7 Tyrone 2 Edinb 0 Norwch 4 Newry 0 Wolve 2 Cardff 6 Bangor 0 Newc 1 Glouc 4 Inverns 1 L H&CX 1 Sheff 2 Livrpl 3 Swanse 0 Airdrie 5 Dundee 1 Redng 1 Klmarnk 1 Dorset 7 Belfast 2 Leic 12 Carsh 1 Oxford 1 Ports 2 Hull 1 Middlbr 2 GlasWI 0 Derby 3 B QEH 2 GlasRI 1 Dunfn 0 Ipswi 1 Basldn 3 Sthend 19 ManWst 1 Truro 2 Sund 1 Exeter 17 Stevng 2 Chelms 2 Abrdn 3 Prestn 7 Carlis 2 Covnt 0 Nottm 7 L Rfree 18 Wrexm 0 L Kings 11 L Guys 6 B Heart 8 Plymth 31 Camb 16 Dudley 0 D&Gall 31 Brightn 10 Eng 6 NI 2 Sct 5 Wls 8 UK Figure 8.8: Percentage of HD patients with Hb 511 g/dl 122

9 Chapter 8 Management of Anaemia in Haemodialysis and Peritoneal Dialysis Patients 8 UK 5 Wls 2 Sct 6 NI 10 Eng 31 Brightn 16 Dudley 0 D&Gall 31 Camb 18 Wrexm 8 Plymth 0 L Kings 11 L Guys 0 Derby 1 Basldn 6 B Heart 19 ManWst 2 Sund 7 L Rfree 1 Dunfn 7 Carlis 2 GlasRI 1 Exeter 2 GlasWI 3 B QEH 6 Bangor 2 Chelms 2 Covnt 2 Hull 3 Prestn 3 Sthend 1 Ports 1 Klmarnk 5 Dundee 1 Glouc 1 Middlbr 7 Belfast 17 Stevng 12 Carsh 0 Airdrie 0 Nottm 1 Oxford 1 Redng 0 Ipswi 1 Dorset 2 Abrdn 0 Newc 1 L H&CX 2 Leic 2 Livrpl 3 Swanse 1 Truro 1 Sheff 2 Cardff 4 Inverns 0 Ulster 7 Tyrone 0 Wolve 0 Norwch 0 Leeds 0 Shrew 0 Bradfd 2 Edinb 6 Clwyd 4 Newry 8 Antrim < Percentage of patients Figure 8.9: Distribution of haemoglobin in patients on HD 123

10 The UK Renal Registry The Ninth Annual Report Percentage of patients Sthend 1 Truro 8 Antrim 0 Ipswi 0 Ulster 1 Redng 6 Clwyd 4 Newry 1 Exeter 0 Nottm 4 Inverns 1 Basldn 17 Stevng 2 Hull 2 Edinb 0 Airdrie 2 Abrdn 5 Dundee 2 Chelms 7 L Rfree 1 Dorset 1 Dunfn 2 Covnt 0 Shrew 2 Leic 8 Plymth 0 Norwch 6 Bangor 3 Prestn 2 GlasRI 1 Oxford 0 D&Gall 1 L H&CX 7 Carlis 7 Tyrone 12 Carsh 1 Middlbr 0 L Kings 6 B Heart 3 Swanse 1 Sheff 2 GlasWI 31 Brightn 11 L Guys 0 Newc 0 Leeds 3 B QEH 18 Wrexm 19 ManWst 1 Klmarnk 0 Wolve 1 Glouc 7 Belfast 1 Ports 2 Cardff 0 Derby 31 Camb 2 Livrpl 16 Dudley 2 Sund 0 Bradfd 10 Eng 6 NI 2 Sct 5 Wls 8 UK Figure 8.10: Percentage of HD patients with Hb and g/dl Upper % Cl % with Hb Lower % Cl Percentage with Hb 10 g/dl % with Hb 10 g/dl 3 SD +3 SD 2 SD +2 SD Mean Number of patients in renal unit Figure 8.11: Funnel plot for percentage of HD patients with Hb 510 g/dl Hb, compliance is unlikely to be greater than % unless the Hb distribution can be systematically narrowed. The funnel plot for haemoglobin outcome allows a unit to identify whether its Hb outcome is statistically different from the national distribution of Hb outcomes. This is true for high or low unit Hb outcomes. In the context of the NICE guidelines this may become increasingly useful to use in conjunction with a measure of compliance with g/dl outcome range. A funnel plot for compliance with UK minimum standards for Hb is shown in Figure 8.11 and should be used in conjunction with Table 8.3 to identify an individual unit by size (X axis) and percentage achieving Hb >10 g/dl (Y axis). Haemoglobin of prevalent peritoneal dialysis patients The compliance with data returns and haemoglobin outcome for peritoneal dialysis patients are shown in Table 8.4. The median haemoglobin for peritoneal dialysis patients by unit and compliance with the UK minimum standard Hb 510 g/dl and 124

11 Chapter 8 Management of Anaemia in Haemodialysis and Peritoneal Dialysis Patients Table 8.3: Percentage of HD patients achieving Renal Association audit standard of Hb 510 g/dl by unit for 2005 Total % with Hb 510 g/dl Abrdn 1 88 Airdrie Antrim 98 B Heart 2 81 B QEH 6 84 Bangor Basldn Belfast Bradfd Brightn Bristol 381 Camb Cardff 363 Carlis Carsh Chelms 84 Clwyd Covnt 247 D&Gall Derby Dorset Dudley 89 Dundee Dunfn Edinb Exeter GlasRI GlasWI Glouc Hull 262 Inverns Ipswi Total % with Hb 510 g/dl Klmarnk 96 L Guys L H&CX L Kings L Rfree 4 83 Leeds Leic Livrpl ManWst 1 82 Middlbr Newc Newry 77 Norwch Nottm Oxford Plymth Ports 302 Prestn 291 Redng Sheff 516 Shrew Stevng Sthend 107 Sund Swanse Truro Tyrone 92 Ulster Wirral 10 Wolve Wrexm York 86 EBPG standard of Hb 511 g/dl are shown in Figures 8.12, 8.13 and The compliance with the new NICE guidelines for outcome haemoglobin g/dl is shown in Figure Again, the dataset predates the NICE guidelines published in In Table 8.4 the inter-quartile range for the UK for the PD population is also 1.9 g/dl (as for HD). The same comments apply regarding compliance for the PD population as for the HD population. The distribution of haemoglobin in peritoneal dialysis patients is shown in Figure A funnel plot for compliance with UK minimum standards for Hb in peritoneal dialysis is shown in Figure The graph is to be used in reference with Table 8.5. Haemoglobin in incident patients The percentage of new and prevalent patients compliant with Hb g/dl is shown in Figure Compliance with UK and EBPG standards in each unit are correlated with the median Hb outcome in each unit. This is shown in Figures These graphs demonstrate that, in general, it is necessary to shift the distribution of haemoglobin values in a population to the right in order to ensure that only a small proportion of the population have values falling below a given audit standard. However, 125

12 The UK Renal Registry The Ninth Annual Report Table 8.4: Haemoglobin data for prevalent patients on peritoneal dialysis % data return Median Hb g/dl % range Quartile range Mean Hb g/dl Standard deviation % with Hb 510 % with Hb 511 Abrdn Airdrie Antrim 83 n/a n/a n/a n/a n/a n/a n/a B Heart B QEH Bangor Basldn Belfast Bradfd Brightn Bristol Camb Cardff Carlis n/a n/a n/a n/a n/a n/a n/a Carsh Chelms Clwyd 92 n/a n/a n/a n/a n/a n/a n/a Covnt D&Gall n/a n/a n/a n/a n/a n/a n/a Derby Dorset Dudley Dundee Dunfn Edinb Exeter GlasRI GlasWI Glouc Hull Inverns 42 n/a n/a n/a n/a n/a n/a n/a Ipswi Klmarnk L Barts 0 n/a n/a n/a n/a n/a n/a n/a L Guys L H&CX L Kings L Rfree Leeds Leic Livrpl ManWst Middlbr n/a n/a n/a n/a n/a n/a n/a Newc Newry 86 n/a n/a n/a n/a n/a n/a n/a Norwch

13 Chapter 8 Management of Anaemia in Haemodialysis and Peritoneal Dialysis Patients Table 8.4: (continued) % data return Median Hb g/dl % range Quartile range Mean Hb g/dl Standard deviation % with Hb 510 % with Hb 511 Nottm Oxford Plymth Ports Prestn Redng Sheff Shrew Stevng Sthend n/a n/a n/a n/a n/a n/a n/a Sund n/a n/a n/a n/a n/a n/a n/a Swanse Truro Tyrone n/a n/a n/a n/a n/a n/a n/a Ulster n/a n/a n/a n/a n/a n/a n/a Wirral 4 n/a n/a n/a n/a n/a n/a n/a Wolve Wrexm York Eng NI Sct Wls UK Note: Median Hb for units with less than 20 new patients or data returns <% are not shown Haemoglobin g/dl Upper quartile Median Lower quartile N = 3,727 0 Bangor 20 Wrexm 0 Newc 0 Wolve 0 Basldn 0 L Kings 0 Camb 0 Shrew 4 Livrpl 2 Ipswi 0 Bradfd 1 Swanse 0 Oxford 2 Cardff 0 Dunfn 1 Ports 2 Leeds 0 Norwch 3 Covnt 3 Chelms 6 Carsh 8 Plymth 13 Brightn 0 Truro 0 Sheff 6 Dorset 2 Dundee 0 Exeter 0 Redng 4 Dudley 11 ManWst 6 B QEH 8 Belfast 4 Klmarnk 0 B Heart 4 Hull 5 Abrdn 2 Derby 2 L H&CX 0 Airdrie 1 GlasWI 2 Leic 2 Stevng 2 Prestn 0 L Guys 2 Edinb 4 GlasRI 0 Nottm 3 Glouc 2 L Rfree 9 Eng 11 NI 7 Sct 5 Wls 8 UK Figure 8.12: Median haemoglobin: PD 127

14 The UK Renal Registry The Ninth Annual Report Percentage of patients Upper % Cl % with Hb 10 N = 3,727 Lower % Cl 0 Bangor 0 Bradfd 8 Plymth 0 Shrew 0 Camb 0 Wolve 20 Wrexm 2 Ipswi 4 Livrpl 0 Airdrie 2 Cardff 2 Leeds 2 Dundee 0 Dunfn 0 Truro 3 Chelms 6 Carsh 2 L H&CX 2 Derby 4 Klmarnk 4 GlasRI 0 Norwch 8 Belfast 0 Redng 2 Stevng 0 B Heart 0 Exeter 0 Basldn 0 Sheff 6 Dorset 1 Ports 0 Oxford 0 L Kings 0 Nottm 0 L Guys 1 Swanse 13 Brightn 2 L Rfree 0 Newc 2 Leic 5 Abrdn 6 B QEH 3 Glouc 2 Edinb 4 Hull 1 GlasWI 4 Dudley 3 Covnt 11 ManWst 2 Prestn 9 Eng 11 NI 7 Sct 5 Wls 8 UK Figure 8.13: Percentage of PD patients with Hb 510 g/dl Percentage of patients Upper % Cl % with Hb 11 N = 3,727 Lower % Cl 0 Wolve 0 Bangor 2 Ipswi 2 Dundee 20 Wrexm 0 Shrew 0 Bradfd 0 Basldn 4 Livrpl 0 Dunfn 6 Dorset 2 Leeds 2 Cardff 0 Truro 13 Brightn 0 L Kings 8 Plymth 0 Camb 4 Klmarnk 0 Airdrie 8 Belfast 0 Norwch 0 Oxford 6 Carsh 3 Chelms 0 Redng 2 L H&CX 5 Abrdn 1 Swanse 2 Derby 0 Newc 0 L Guys 6 B QEH 0 Sheff 0 Exeter 1 Ports 4 Hull 4 GlasRI 1 GlasWI 0 Nottm 2 Leic 0 B Heart 2 Stevng 3 Covnt 4 Dudley 11 ManWst 2 L Rfree 3 Glouc 2 Prestn 2 Edinb 9 Eng 11 NI 7 Sct 5 Wls 8 UK Figure 8.14: Percentage of PD patients with Hb 511 g/dl Percentage of patients Upper % Cl % with Hb 10 Lower % Cl 0 0 Airdrie 0 Nottm 0 B Heart 2 L Rfree 4 GlasRI 8 Belfast 0 Truro 2 Dundee 2 Derby 2 L H&CX 4 Klmarnk 0 Bradfd 0 Exeter 8 Plymth 2 Stevng 0 Norwch 1 GlasWI 6 Dorset 0 Dunfn 2 Leic 0 L Guys 6 Carsh 2 Ipswi 4 Livrpl 0 Redng 2 Prestn 0 Wolve 0 Camb 1 Swanse 5 Abrdn 0 Oxford 3 Glouc 0 Sheff 2 Leeds 2 Cardff 4 Hull 6 B QEH 0 Shrew 13 Brightn 0 L Kings 2 Edinb 3 Covnt 0 Basldn 3 Chelms 20 Wrexm 1 Ports 11 ManWst 4 Dudley 0 Newc 0 Bangor 9 Eng 11 NI 7 Sct 5 Wls 8 UK Figure 8.15: Percentage of PD patients with Hb and g/dl 128

15 Chapter 8 Management of Anaemia in Haemodialysis and Peritoneal Dialysis Patients 8 UK 5 Wls 7 Sct 11 NI 9 Eng 2 Prestn 11 ManWst 3 Covnt 4 Dudley 1 GlasWI 4 Hull 2 Edinb 3 Glouc 5 Abrdn 6 B QEH 2 Leic 0 Newc 2 L Rfree 13 Brightn 1 Swanse 0 L Guys 0 Nottm 0 L Kings 0 Oxford 1 Ports 6 Dorset 0 Sheff 0 Basldn 0 Exeter 0 B Heart 2 Stevng 0 Redng 8 Belfast 0 Norwch 4 GlasRI 4 Klmarnk 2 Derby 2 L H&CX 6 Carsh 3 Chelms 0 Truro 0 Dunfn 2 Dundee 2 Leeds 2 Cardff 0 Airdrie 4 Livrpl 20 Wrexm 2 Ipswi 0 Wolve 0 Camb 0 Shrew 8 Plymth 0 Bradfd 0 Bangor < Percentage of patients Figure 8.16: Distribution of haemoglobin in patients on PD 129

16 The UK Renal Registry The Ninth Annual Report Percentage with Hb 10 g/dl % with Hb 10 g/dl 3 SD +3 SD 2 SD +2 SD Mean Number of patients in unit Figure 8.17: Funnel plot for percentage of PD patients with Hb 510 g/dl Table 8.5: Percentage of PD patients achieving Hb 510 g/dl by unit Total % with Hb 510 g/dl Abrdn Airdrie B Heart B QEH Bangor 22 Basldn 30 Belfast Bradfd 38 Brightn Bristol 62 Camb 99 Cardff Carsh Chelms Covnt Derby Dorset 59 Dudley Dundee 43 Dunfn 21 Edinb 54 Exeter 82 GlasRI GlasWI Glouc 34 Hull 52 Total % with Hb 510 g/dl Ipswi Klmarnk L Guys L H&CX L Kings 67 L Rfree Leeds Leic Livrpl 96 ManWst Newc Norwch Nottm Oxford 106 Plymth 33 Ports 88 Prestn Redng 91 Sheff 149 Shrew 40 Stevng Swanse Truro Wolve Wrexm York

17 Chapter 8 Management of Anaemia in Haemodialysis and Peritoneal Dialysis Patients Percentage of patients 40 New patients Prevalent dialysis patients 30 Antrim B Heart B QEH Bangor Basldn Belfast Bradfd Brightn Bristol Camb Cardff Carlis Carsh Chelms Clwyd Covnt Derby Dorset Dudley Exeter Glouc Hull Ipswi L Guys L H&CX L Kings L Rfree Leeds Leic Livrpl ManWst Middlbr Newc Norwch Nottm Oxford Plymth Ports Prestn Redng Sheff Shrew Stevng Sthend Sund Swanse Truro Tyrone Wolve Wrexm York Eng NI Wls UK Figure 8.18: Percentage of new and prevalent dialysis patients with Hb 510 g/dl Percentage Hb 10 g/dl Percentage Hb 10 g/dl Median Hb Figure 8.19: Percentage of patients with Hb 510 g/dl plotted against median Hb: HD Median Hb Figure 8.21: Percentage of patients with Hb 510 g/dl plotted against median Hb: PD Percentage Hb 11 g/dl Median Hb Figure 8.20: Percentage of patients with Hb 511 g/dl plotted against median Hb: HD Percentage Hb 11 g/dl Median Hb Figure 8.22: Percentage of patients with Hb 511 g/dl plotted against median Hb: PD 131

18 The UK Renal Registry The Ninth Annual Report they also demonstrate that there is considerable variation between units in the relationship between median Hb and percentage achieving the audit standard; some units are able to achieve a high proportion meeting the standard at a lower median Hb than others. This is achieved by narrowing the distribution of Hb values. Tables 8.2 and 8.4 also demonstrate this: the standard deviation for Hb values varies considerably between units. Preliminary analysis of previous years data shows that some renal units have achieved a narrow distribution of Hb values year on year for instance, Truro. Those with a low standard deviation have succeeded in narrowing the distribution of Hb values, and are therefore able to achieve a higher proportion of patients with Hb values above the minimum audit standard without also achieving a high proportion of patients with high Hb values. The Upper % CI % with Hb 10 Lower % CI Percentage Hb 10 g/dl 55 Haemodialysis Peritoneal dialysis Figure 8.23: Percentage of dialysis patients with Hb 510 g/dl Upper % CI % with Hb 10 Lower % CI Percentage Hb 10 g/dl New patients Prevalent dialysis patients Figure 8.24: Percentage of new dialysis patients with Hb 510 g/dl

19 Chapter 8 Management of Anaemia in Haemodialysis and Peritoneal Dialysis Patients accumulating evidence that full correction of anaemia may be harmful in kidney disease, together with the high cost of full correction, should drive attempts to learn from those units that have successfully narrowed the distribution of values. Haemoglobin outcome in England and Wales for haemodialysis and peritoneal dialysis populations in terms of compliance with Hb g/dl continue to increase year on year (Figure 8.23). Equally, compliance for Hb g/dl in patients new to dialysis in England and Wales continues to increase (Figure 8.24). Changes in Haemoglobin by length of time on dialysis over time In the haemodialysis population the median haemoglobin outcome improves in the first 6 months to become compliant with the UK minimum standard and remains stable up to 2 years post commencement of dialysis therapy. In the peritoneal dialysis population however the Hb outcome improves out to 1 year and then decreases out to 2 years. It is uncertain whether this reflects fall in residual renal function, salt and water overload, or other factors as yet undetermined. The actual outcome in the PD population however, decreases to the same level as for HD patients from a higher baseline (Figures 8.25, 8.26). Hb g/dl HD 1999 HD 2000 HD 2001 HD 2002 HD 2003 HD 2004 HD <6 months 6 m 1 yr 1 2 yrs >2 years Median all Years Figure 8.25: Median Haemoglobin by length of time on RRT: HD Hb g/dl PD 1999 PD 2000 PD 2001 PD 2002 PD 2003 PD 2004 PD <6 months 6 m 1 yr 1 2 yrs >2 years Median all Years Figure 8.26: Median Haemoglobin by length of time on RRT: PD 133

20 The UK Renal Registry Factors affecting Haemoglobin National and international recommendations for target iron status in chronic kidney disease remain unchanged from previous reports. The 2002 Renal Association Standards Document (SDIII) 2, revised European Best Practice Guidelines (EBPGII) 3 and Dialysis Outcomes Quality Initiatives (DOQI) guidelines 4 and UK NICE Anaemia guidelines 5 all recommend: a target serum ferritin greater than lg/l and percentage transferrin saturation (TSAT) more than 20% in patients with chronic kidney disease SDIII and EBPGII recommend: less than 10% hypochromic red cells (HRC) (evidence level B) in addition, EBPGII adds: a target reticulocyte Hb content (CHr) greater than 29 pg/cell (evidence level B) KDOQI recommends ferritin >200 lg/l for HD patients The NICE Guidelines suggest a hypochromic red cells value >6% suggests ongoing iron deficiency (HRC) To achieve adequate iron status across a patient population, SDIII and EBPGII advocate population targets for ferritin of mg/l, for TSAT of 30 40%, for hypochromic red cells of <2.5% and CHr of 35 pg/cell. EBPGII comments that a serum ferritin target for the treatment population of mg/l ensures that % of patients attain a serum ferritin of mg/l. All guidelines advise that: serum ferritin levels should not exceed 0 lg/l since the risk of iron toxicity increases without conferring additional benefit. The KDOQI and NICE guidelines advise against IV iron administration to patients with a ferritin >0 lg/l. Serum ferritin has several disadvantages as an index of iron status. It measures storage iron rather than available iron; behaves as an acute phase reactant, and is therefore increased in inflammatory states, malignancy and liver disease; and may not accurately reflect iron stores if measured within a week of the The Ninth Annual Report administration of intravenous iron. Of the alternative measures of iron status available, HRC and CHr are generally considered superior to TSAT. Both however require specialised analysers to which few UK renal units have easy access. Since TSAT is measured infrequently in many centres, and most UK units continue to use serum ferritin for routine iron management, ferritin remains the chosen index of iron status for this report. Information on the use of Erythropoietin Stimulating Agents was excluded from the 2003 report due to data collection problems. These problems were addressed, allowing ESA data from 23 units to be presented in the 2004 report and for 30 units in the 2005 report. In the 2006 report these data remain incomplete but have improved with 36 units returning ESA data. Work continues to establish more comprehensive ESA returns. Data are presented as total weekly erythropoietin dose. Doses of darbepoietin were harmonised with erythropoietin data by multiplying by 200 and correcting for any frequency of administration less than weekly. No adjustments are made with regard to frequency or route of administration. Completeness of serum ferritin returns for HD and PD The completeness of serum ferritin returns to the Registry is shown in Table 8.6. Not all sites use serum ferritin as the sole indicator of iron status. Completeness of ferritin returned from England and Wales improved compared to Scotland is included here for the first time. Lack of an automated biochemistry or haematology link into the IT renal system might account for a very low rate of return in some units. In other cases of missing data, renal units may need to address organisational processes to ensure that serum ferritin is checked. Serum ferritin Percentage returns, median serum ferritin concentrations and interquartile ranges are presented in Table 8.7 and Figure 8.27 for haemodialysis and Table 8.8 and Figure 8.28 for peritoneal dialysis. The percentages of patients achieving a serum ferritin over mg/l and over 200 mg/l are shown in Figures 8.29 and 134

21 Chapter 8 Management of Anaemia in Haemodialysis and Peritoneal Dialysis Patients Table 8.6: Completeness of serum ferritin returns HD % PD % Abrdn 1 0 Airdrie 0 0 Antrim B Heart 94 B QEH Bangor 94 Basldn 99 Belfast Bradfd Brightn Bristol Camb Cardff Carlis 93 Carsh 82 Chelms Clwyd 92 Covnt 98 D&Gall 0 0 Derby Dorset Dudley Dundee 0 2 Dunfn 0 0 Edinb 0 0 Exeter GlasRI 0 0 GlasWI 0 0 Glouc Hull Inverns 0 0 Ipswi Klmarnk 0 0 L Barts 1 0 L Guys 87 HD % PD % L H&CX L Kings L Rfree Leeds 98 Leic 96 Livrpl ManWst Middlbr 97 Newc Newry Norwch Nottm Oxford 89 Plymth Ports Prestn Redng Sheff 99 Shrew Stevng Sthend 96 Sund 93 Swanse Truro 98 Tyrone 3 Ulster Wirral 3 0 Wolve 99 Wrexm 82 York Eng 89 NI Sct 0 0 Wls 94 UK 81 % data return Table 8.7: Serum ferritin in HD patients Median ferritin % range Quartile range % ferritin 5 mg/l Antrim B Heart B QEH Bangor , Basldn Belfast , Bradfd , Brightn , Bristol , Camb ,

22 The UK Renal Registry The Ninth Annual Report Table 8.7: (continued) % data return Median ferritin % range Quartile range % ferritin 5 mg/l Cardff , Carlis Carsh Chelms , Clwyd Covnt Derby , Dorset Dudley Exeter Glouc Hull Ipswi , L Barts 1 n/a n/a n/a n/a L Guys , L H&CX , L Kings L Rfree , Leeds Leic 3 1, Livrpl , ManWst 541 1, Middlbr , Newc Newry , Norwch , , Nottm , Oxford Plymth Ports Prestn , Redng , Sheff , Shrew Stevng Sthend Sund , Swanse Truro Tyrone 3 n/a n/a n/a n/a Ulster Wirral 3 n/a n/a n/a n/a Wolve , Wrexm , York Eng , NI , Wls UK ,

23 Chapter 8 Management of Anaemia in Haemodialysis and Peritoneal Dialysis Patients Ferritin mg/l N = 11,6 Upper quartile Median ferritin Lower quartile 0 Norwch 2 Redng 0 Prestn 6 Bangor 0 Nottm 1 L H&CX 1 Sheff 40 ManWst 4 Livrpl 18 Wrexm 0 Bradfd 0 Leeds 4 Cardff 1 Stevng 2 Truro 2 Chelms 10 Belfast 3 Derby 1 Wolve 1 Dorset 3 Middlbr 0 L Kings 1 Newry 4 Antrim 0 Ulster 0 Newc 13 L Guys 2 Ipswi 16 L Rfree 3 Hull 2 Swanse 2 Plymth 7 Sund 2 Glouc 0 Shrew 5 Leic 27 Dudley 4 Sthend 7 Carlis 0 Exeter 1 Basldn 10 Clwyd 18 Carsh 11 Oxford 36 Brightn 2 Covnt 2 Ports 3 B QEH 35 Camb 6 B Heart 11 Eng 21 NI 5 Wls 20 UK Figure 8.27: Median serum ferritin: haemodialysis Table 8.8: Serum ferritin in PD patients % data return Median ferritin % range Quartile range % ferritin 5 mg/l Antrim 94 n/a n/a n/a n/a B Heart B QEH Bangor Basldn Belfast , Bradfd Brightn Bristol Camb Cardff Carlis n/a n/a n/a n/a Carsh Chelms Clwyd 92 n/a n/a n/a n/a Covnt Derby Dorset Dudley Exeter Glouc Hull Ipswi L Barts 0 n/a n/a n/a n/a L Guys L H&CX , L Kings L Rfree , Leeds Leic Livrpl

24 The UK Renal Registry The Ninth Annual Report % data return Median ferritin Table 8.8: (continued) % range Quartile range % ferritin 5 mg/l ManWst Middlbr n/a n/a n/a n/a Newc Newry 93 n/a n/a n/a n/a Norwch Nottm Oxford Plymth , Ports Prestn Redng Sheff Shrew Stevng Sthend n/a n/a n/a n/a Sund n/a n/a n/a n/a Swanse Truro Tyrone n/a n/a n/a n/a Ulster n/a n/a n/a n/a Wirral 0 n/a n/a n/a n/a Wolve Wrexm York Eng NI Wls UK Note: Median Hb for units with less than 20 new patients or data returns <% are not shown N = 3,316 Upper quartile Median ferritin Lower quartile Ferritin mg/l Redng 0 Norwch 20 Wrexm 3 L Rfree 2 Leeds 0 Nottm 5 Newc 14 Derby 5 Bangor 2 Hull 0 Bradfd 14 Brightn 0 Shrew 4 Leic 0 Sheff 0 L Kings 3 Dorset 2 L H&CX 3 Plymth 9 Chelms 2 Livrpl 0 Prestn 4 Ports 5 Oxford 0 L Guys 15 Covnt 8 Dudley 10 ManWst 0 Exeter 15 Belfast 3 Cardff 1 Swanse 0 Camb 0 Truro 0 Basldn 0 Wolve 22 Ipswi 9 Glouc 0 B Heart 2 Stevng 15 Carsh 4 B QEH 10 Eng 12 NI 6 Wls 19 E&W&NI Figure 8.28: Median serum ferritin: peritoneal dialysis 138

25 Chapter 8 Management of Anaemia in Haemodialysis and Peritoneal Dialysis Patients Percentage ferritin mg/l Upper % CI % with ferritin Lower % CI N = 11,6 6 Bangor 10 Clwyd 1 Newry 2 Redng 3 Hull 0 Norwch 2 Truro 4 Cardff 1 Dorset 4 Sthend 1 Stevng 2 Chelms 0 Nottm 7 Carlis 1 Basldn 0 Exeter 0 Bradfd 1 Wolve 0 Newc 18 Wrexm 0 Leeds 0 Ulster 0 L Kings 2 Plymth 4 Antrim 1 L H&CX 0 Shrew 3 Derby 0 Prestn 10 Belfast 1 Sheff 7 Sund 4 Livrpl 2 Swanse 16 L Rfree 2 Ports 5 Leic 3 Middlbr 3 B QEH 40 ManWst 18 Carsh 13 L Guys 27 Dudley 2 Glouc 2 Ipswi 11 Oxford 6 B Heart 2 Covnt 35 Camb 36 Brightn 11 Eng 21 NI 5 Wls 20 E&W&NI Figure 8.29: Percentage of HD patients with serum ferritin 5 mg/l Percentage ferritin 200 mg/l 55 Upper % CI % with ferritin 200 N = 11,6 Lower % CI 2 Redng 0 Norwch 2 Truro 6 Bangor 2 Chelms 18 Wrexm 0 Bradfd 0 Nottm 4 Sthend 1 Stevng 0 Newc 0 Leeds 0 Prestn 1 Wolve 3 Derby 3 Hull 4 Cardff 1 Dorset 1 Sheff 1 Newry 0 L Kings 1 L H&CX 10 Clwyd 4 Antrim 10 Belfast 0 Exeter 1 Basldn 2 Plymth 7 Carlis 0 Ulster 13 L Guys 3 Middlbr 16 L Rfree 4 Livrpl 27 Dudley 2 Glouc 2 Swanse 7 Sund 40 ManWst 5 Leic 0 Shrew 2 Ports 18 Carsh 2 Ipswi 3 B QEH 11 Oxford 2 Covnt 36 Brightn 35 Camb 6 B Heart 11 Eng 21 NI 5 Wls 20 E&W&NI Figure 8.30: Percentage of HD patients with serum ferritin 5200 mg/l Percentage ferritin mg/l Wrexm 0 Norwch 2 Leeds 14 Derby 2 Hull 3 Dorset 9 Chelms 14 Brightn 4 Redng 0 Nottm 5 Newc 3 L Rfree 4 Leic 9 Glouc 2 Livrpl 0 Shrew 0 Sheff 0 L Kings 4 Ports 0 L Guys 2 L H&CX 0 Truro 10 ManWst 0 Wolve 0 Prestn 5 Bangor 0 Exeter 2 Stevng 0 Bradfd 1 Swanse 8 Dudley 5 Oxford 3 Plymth 15 Belfast 0 B Heart 15 Covnt 0 Camb 15 Carsh 0 Basldn 3 Cardff 22 Ipswi 4 B QEH 10 Eng 12 NI 6 Wls 19 E&W&NI N = 3,316 Figure 8.31: Percentage of PD patients with serum ferritin 5 mg/l Upper % CI % with ferritin Lower % CI 139

26 The UK Renal Registry The Ninth Annual Report Percentage ferritin 200 mg/l N = 3,316 Upper % CI % with ferritin 200 Lower % CI 20 4 Redng 20 Wrexm 2 Leeds 14 Derby 0 Shrew 0 Nottm 3 Dorset 2 Hull 3 L Rfree 0 Sheff 0 Bradfd 5 Newc 14 Brightn 4 Leic 5 Bangor 2 Livrpl 0 L Kings 2 L H&CX 9 Chelms 0 Prestn 0 L Guys 4 Ports 5 Oxford 8 Dudley 3 Plymth 10 ManWst 15 Belfast 3 Cardff 0 Exeter 1 Swanse 15 Covnt 0 Truro 0 Wolve 0 Camb 22 Ipswi 0 Basldn 4 B QEH 2 Stevng 9 Glouc 15 Carsh 0 B Heart 10 Eng 12 NI 6 Wls 19 E&W&NI Figure 8.32: Percentage of PD patients with serum ferritin 5200 mg/l 8.30 respectively, for HD, and for PD in Figures 8.31 and Percentage of serum ferritin mg/l in HD and PD are shown in Table 8.9. All centres achieved greater than % compliance with a serum ferritin over mg/l for HD. The PD population has lower ferritin values (PD 256 mg/l, (IQR ) vs HD 413 mg/l, (IQR )) but all units have Table 8.9: Percentage of patients with serum ferritin mg/l HD % Ferritin % CI % Ferritin % CI Antrim n/a B Heart B QEH Bangor Basldn Belfast Bradfd Brightn Bristol Camb n/a Cardff Carlis n/a Carsh Chelms n/a Clwyd n/a Covnt n/a Derby Dorset Dudley Exeter Glouc Hull Ipswi L Barts L Guys PD 140