Chairman's introduction

llwoffidd.Joumalofti

American Journal of Kidney Diseases CHAIRMAN’S

National

INTRODUCTION

T IS GENERALLY agreed that increasing hematocrit levels with epoetin therapy in patients on dialysis improves patient outcomes by improving numerous aspects of quality of life and enhancing the potential for rehabilitation. However, there has been slow acceptance by the nephrology community to increase hematoctit to a level that would optimize patient response. As shown in Fig 1, which is based on data from 1,000 patients at 200 dialysis centers, average hematocrit levels from the beginning of 1993 through the third quarter of 1994 remained relatively stable at approximately 30%, despite the fact that the suggested target hematocrit range has been broadened to between 30% and 36%. Why, then, is the nephrology community apparently reluctant to increase hematocrit to levels that are legally reimbursable in the United States? Is it because physicians do not know how to administer epoetin at an appropriate dose? Are these patients iron deficient? Or are there unfounded concerns about potential adverse effects of increased hematocrit levels? These issues, as well as many others, were discussed during an official satellite symposium of the American Society of Nephrology 27th Annual Meeting and Exposition held in Orlando, FL, on October 26, 1994. The symposium, entitled ‘ ‘Improving Patient Outcomes With Higher Hematocrit Levels,” focused on the advantages of increasing hematocrit levels and the impact on dialysis units. Dr John D. Hamett, Associate Professor of Medicine, Memorial University of Newfoundland, Health Sciences Center, Division of Nephrology, St Johns, Newfoundland, Canada, discussed cardiac function and hematocrit level. During his presentation, Dr Hamett addressed the role of anemia Journal

Foundation

VOL 25, NO 4, SUPPL 1, APRIL 1995

I

American

Kidney

of Kidney

Diseases,

Vol25,

No 4, Suppl

as a risk factor for cardiovascular complications in patients on dialysis and reviewed data from a recently completed prospective study that was performed at three Canadian dialysis centers. In the area of assessing patient outcomes, Dr Paul S. Kurtin, Vice President, Quality and Resource Management, Children’s Hospital and Health Center, San Diego, CA, discussed the need for establishing operational definitions and survey instruments to provide health care professionals with a common understanding of what constitutes appropriate quality care for patients with end-stage renal disease. The symposium concluded with a discussion on adapting the dialysis unit to increased hematocrit levels. Dr Emil Paganini, Chairman, Section of Dialysis and Extracorporeal Therapy, Department of Hypertension/ Nephrology, The Cleveland Clinic Foundation, Cleveland, OH, addressed physician concerns regarding vascular access, solute clearance, and blood pressure when hematocrit levels are increased above 30%. In his presentation, Dr Paganini noted that any potential problems associ-

40-

T t 8

30-

hvwage

. .

. .

20-

Avem!~a ol petienta QOY.

lo-

I a1 1693

I a2 1993

I 1%

I 04 1993

I a1 1994

I 02 1694

I a3 1994

Fig 1. Average hematocrit level by quarter and percent in all pathnts and in pathts with hematocrit levels < 30%. Data on file at Amgen Inc. and based on 1,ooO patient records at 200 dialysis centers. 1 (April),

1995:

pp Sl-S2

Sl

s2

ated with higher hematocrit levels are easily resolved through minor alterations in the dialysis prescription. Kt/V for urea is trivially affected by increases in hematocrit, whereas possible reductions in potassium and phosphate clearance are more effectively dealt with by dialysate po-

NATHAN

W. LNIN

tassium ion reduction or use of phosphate binders, respectively. I hope you find this information useful in helping your patients optimize their outcomes as a result of increased hematocrit levels. Nathan W. Levin, MD, FACP