Date Published: 
Monday, 2 June, 2014

A high proportion of older patients approaching end-stage renal disease undergo blood transfusions despite the development of new treatments, data indicate

Professor Jorge Toblli

Blood transfusion avoidance is an important goal in the management of patients with end-stage renal disease (ESRD). However, despite the increased use of agents to treat anaemia and iron deficiency over the last 15 years, the proportion of these patients receiving blood transfusions has doubled. 

Anaemia is a hallmark complication in ESRD. Although blood transfusions are a treatment option, repeated transfusions in these patients can lead to incidences of hyperkalemia, iron overload and heart failure1. Over the last two decades, new agents have been developed to treat anaemia and reduce the need for transfusions.

In this retrospective study, the authors identified ESRD patients who began dialysis or underwent pre-emptive kidney transplantation in the United States between 1995 and 2010. Approaches to anaemia treatment were assessed in these patients.

Over the 15-year assessment period, the proportion of patients with ESRD receiving erythropoiesis-stimulating agents (ESAs) increased from 3.2% to 35.0% (prevalence ratio [PR], 9.85 [95% CI: 9.04–10.74]), and intravenous iron increased from 1.2% to 12.3% (PR, 9.20 [95 CI: 7.97–10.61]). Surprisingly, the mean haemoglobin concentration only moderately increased from 9.5 to 9.9 g/dL. Despite the substantial rise in use of ESAs and iron therapy, almost twice as many of these patients received blood transfusions to treat anaemia.

In this article, Winkelmayer and colleagues highlight one of the most important problems in the management of patients with chronic kidney disease – identifying the right indication for blood transfusions. In a careful analysis, they stressed that the proportion of patients receiving blood transfusions has increased in the last decade, despite continuous efforts by medical associations (such as the National Kidney Foundation and American Society of Nephrology) to encourage physicians to avoid or restrict their use. The message of this article is crucial in order to persuade physicians involved in the medical care of patients with anaemia and chronic kidney disease to use a more conservative approach to blood transfusions.

The increased proportion of ESRD patients who received a transfusion may be a consequence of clinicians being increasingly liberal in conducting transfusions, driven more by a haemoglobin concentration target, rather than the prevalence of symptomatic anaemia. The authors therefore conclude that there is an important need to develop safe, effective, and economical anaemia treatment strategies in patients with ESRD.

The full article is available in the May 2014 issue of JAMA Internal Medicine. For information on iron deficiency in nephrology, please click here.