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Abstract: PO0271

Temporal Trends in Anemia Management and Major Clinical Outcomes in Incident Dialysis Patients in Canada

Session Information

Category: Anemia and Iron Metabolism

  • 200 Anemia and Iron Metabolism


  • Canney, Mark, The University of British Columbia, Vancouver, British Columbia, Canada
  • Birks, Peter C., BC Provincial Renal Agency, Vancouver, British Columbia, Canada
  • Shao, Selena, BC Provincial Renal Agency, Vancouver, British Columbia, Canada
  • Parfrey, Patrick S., Memorial University of Newfoundland, St. John's, Newfoundland, Canada
  • Djurdjev, Ognjenka, BC Provincial Renal Agency, Vancouver, British Columbia, Canada
  • Levin, Adeera, The University of British Columbia, Vancouver, British Columbia, Canada

Several jurisdictions have adopted a more conservative approach to anemia in patients receiving dialysis amid safety concerns from target hemoglobin trials. Outside of the US, it is unknown if this has contributed to a change in outcomes. In this retrospective national cohort study, we sought to examine the association between the era of anemia management and major clinical outcomes in incident dialysis patients in Canada.


The Canadian Organ Replacement Register was used to identify 35,945 adult patients who initiated hemodialysis or peritoneal dialysis from Jan 1 2007 to Dec 31 2015. Time at risk started on day 90 of dialysis and continued for a minimum of 12 months to capture outcomes via data linkage with hospital discharge diagnoses. Patients were categorized into 3 time periods anchored to landmark target hemoglobin trials and publication of anemia guidelines: Era 1 (Jan 2007-Dec 2009); Era 2 (Jan 2010-Dec 2012); Era 3 (Jan 2013-Dec 2015). Cox proportional hazards regression models were used to investigate the association between era and the primary composite outcome (acute myocardial infarction (AMI), stroke or mortality).


The mean hemoglobin at dialysis initiation decreased from 102.9g/L in 2007 to 95.5g/L in 2015, corresponding with a doubling in the prevalence of hemoglobin <80g/L (8% to 17%) and a reduction in ESA use (49% to 44%). A total of 11,810 events were observed during 66,844 person years of follow-up. After multivariable adjustment, Era 3 was associated with an 8% relative risk reduction in the primary outcome compared to Era 1 (hazard ratio (HR) 0.92, 95% confidence interval (CI) 0.88-0.96), driven by a reduction in all-cause mortality (HR 0.90, 95% CI 0.85-0.94) without a reduction in AMI or stroke. In a model without era, neither hemoglobin nor ESA use was an independent predictor of mortality.


There have been modest declines in average hemoglobin values and ESA use among incident dialysis patients in Canada. Unlike the US, there has been no temporal reduction in stroke. Patient survival has improved over time, likely for reasons other than anemia management. An increasing number of patients are starting dialysis with a hemoglobin <80g/L, which represents a substantial shift in practice and merits further investigation in terms of patient-centered outcomes.