Blood Transfusion during Hemodialysis: An Evidence-Based Procedure

Headnote

Copyright 2014 American Nephrology Nurses' Association

Ashton, D. (2014). Blood transfusion during hemodialysis: An evidence-based procedure. Nephrology Nursing Journal, 41(4), 424-428.

Key Words: Hemodialysis, blood transfusion, chronic kid- ney disease, erythoropoietic stimulating agents, anemia.

QWe are seeing an increase in transfusion rates for our patients on hemodialysis. What actions will help us deliver the blood transfusion in a safe manner?

APatients with acute and chronic kidney disease (CKD) become anemic due to inadequate ery- thropoietin generation and a myriad of other co-morbid conditions. The anemia of CKD is treated with supplemental iron infusions and the adminis- tration of erythropoietic stimulating agents (ESAs), but blood transfusion may also be required, and the need for transfusion is on the rise (U.S. Renal Data System [USRDS], 2013).

Introduction

In 2007, the United States Food and Drug Admini- stration (FDA) reported an increased rate of adverse events, including non-fatal heart attacks, strokes, heart fail- ure, blood clots, and death, in patients with CKD when ESAs were adjusted to achieve and maintain a hemoglo- bin (Hgb) level greater than 12 g/dL. Prescribers were advised to utilize the lowest doses of ESAs to steadily improve the Hgb concentration to a level adequate enough to avoid the need for transfusion. Additionally, prescribers were counseled to avoid a target Hgb greater than 12 g/dL to prevent cardiovascular events (FDA, 2007). A black box warning label (a label added to drug package inserts to warn that the drug carries significant risk of serious or even life-threatening adverse effects) was added to ESA packaging calling attention to these adverse effects. In 2011, the FDA issued a safety announcement recommending an even more conservative dosing of ESAs, stating that in controlled trials with patients with CKD, the same adverse events occurred when a Hgb of greater than 11 g/dL was targeted (FDA, 2011). ESA man- ufacturers changed their prescribing warnings at that time, and they remain the same as of April 2014 (Amgen, 2014).

The Dialysis Outcomes Practice Patterns Study (DOPPS) data from August 2010 to December 2013 indi- cate a decrease in Hgb levels correlating to the FDA- decreased dosing recommendations and payment and regulatory changes in the United States in 2011 (see Figure 1). Data show a decrease in Hgb levels of 12...