Anemia is common among hemodialysis patients, and managing this condition is an essential element of care. Anemia management practices have changed substantially following two major policy changes in the United States in 2011. One of the corresponding changes seen in dialysis patients has been a dramatic rise in average ferritin levels, sustained into 2013.

The Dialysis Outcomes and Practice Patterns Study (DOPPS) examines this sustained rise in ferritin levels in a paper published in the latest issue of the Clinical Journal of The American Society of Nephrology. DOPPS researchers analyzed trends in mean ferritin, hemoglobin, IV iron dose, and erythropoiesis stimulating agent (ESA) dose from 2009 to 2013 among dialysis patients in the United States. Using linear mixed models, the researchers assessed the extent to which IV iron and ESA dose accounted for within-patient changes in ferritin over time.

ESA doses and hemoglobin levels declined throughout the study. Ferritin levels increased sharply in 2011 and remained high through study end. In contrast to what the authors expected to find, mean IV iron dose peaked in 2011 and then returned to 2009-2010 levels thereafter.  Angelo Karaboyas, the first author of this study, noted “the increase in IV iron dosing was surprisingly short-lived.” Statistical models suggest that higher IV iron dosing was a primary determinant of the ferritin increase during 2011 and lower ESA doses contributed to the sustainment of high ferritin levels.

The authors conclude that the rise in ferritin levels in U.S. dialysis patients appears to be partly due to reductions in ESA dosing and not solely IV iron dosing practices. Together, changes in IV iron and ESA doses accounted for 46% of the increase in ferritin over the study period. Further investigation is needed to fully assess the impact of these changes in ferritin on health outcomes for dialysis patients.

January 2011: The Centers for Medicare & Medicaid Services (CMS) launched the ESRD PPS, establishing a single payment under Medicare for all dialysis-related services, eliminating financial incentives for dialysis providers to use greater amounts of separately billable medications and services.

June 2011: The Food and Drug Administration (FDA) approved a change in labeling for ESAs that encouraged more conservative use of ESAs, which are commonly prescribed for patients on dialysis to maintain hemoglobin levels.