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Abstract: TH-PO252

The Impact of Newly Developed Inflammation, Characterized by Rise in C-Reactive Protein, on Anemia Management Practices in Hemodialysis Patients: A Before-After Design in the DOPPS

Session Information

Category: Anemia and Iron Metabolism

  • 202 Anemia and Iron Metabolism: Clinical


  • Karaboyas, Angelo, Arbor Research Collaborative for Health, Ann Arbor, Michigan, United States
  • Morgenstern, Hal, University of Michigan, Ann Arbor, Michigan, United States
  • Vanholder, Raymond C., University Hospital Gent, Gent, Belgium
  • Fleischer, Nancy L., University of Michigan, Ann Arbor, Michigan, United States
  • Schaubel, Douglas E., University of Michigan, Ann Arbor, Michigan, United States
  • Schaeffner, Elke, Charite , Berlin, Germany
  • Akizawa, Tadao, Showa University School of Medicine, Tokyo, Japan
  • Dhalwani, Nafeesa N., Evidera, London, United Kingdom
  • Sinsakul, Marvin, AstraZeneca, Gaithersburg, Maryland, United States
  • Pisoni, Ronald L., Arbor Research Collaborative for Health, Ann Arbor, Michigan, United States
  • Robinson, Bruce M., Arbor Research Collaborative for Health, Ann Arbor, Michigan, United States

Inflammation, as assessed by a rising C-reactive protein (CRP), may lower hemoglobin (Hgb) level and lead to increased ESA dose to support the unmet need.


Using data from Dialysis Outcomes and Practice Patterns Study (DOPPS) phases 4-6 (2009-2018) in 10 countries where CRP is routinely measured, we identified hemodialysis patients who had a new inflammation event, defined here as CRP >10 mg/L following a 3-month period with all available CRP measurements ≤5 mg/L. In a “before-after” design treating patients as their own controls, we used adjusted linear mixed models to estimate within-patient effects of inflammation on changes in Hgb and log-transformed ESA dose, comparing mean values from the 3 months “before” vs. “after” observing high CRP. Sensitivity analyses used different CRP thresholds as a proxy for a new inflammation event (e.g., ≤3 to >10 mg/L, ≤5 to >20 mg/L).


Among 12389 patients, 40158 CRP values (21% of all measurements) were >10 mg/L, and 3752 measurements (from 2976 patients) met the eligibility criteria (Fig). In the “before” vs. “after” periods, mean Hgb was 11.2 vs. 10.9 g/dL and mean ESA dose was 6347 vs. 6994 units/week. In 56% of the cases, patients experienced either a Hgb drop of >0.5 g/dL (40% of cases) or a >20% increase in ESA dose (33% of cases). In adjusted models, the average within-patient change was 0.26 g/dL (95% CI: 0.22, 0.30) lower Hgb and an 8.6% (95% CI: 6.4, 10.8) increase in ESA dose. Results were robust to sensitivity analyses varying the CRP thresholds.


After patients experienced an inflammation event, Hgb levels declined and ESA doses rose, suggestive of increased ESA resistance. Routine measurement of CRP is not practiced in the US but could help identify inflamed patients. These patients may benefit from proactive adjustment of medications or, in the future, anemia therapies that may be less subject to effects of inflammation.


  • NIDDK Support