2025 Southeastern Residency Conference

Authors: Akua Kuffour, Brianna Qualls, Christine Wong, Devon Tousignant 
Purpose: Erythropoiesis-stimulating agents (ESAs) are commonly utilized in the management of anemia associated with chronic kidney disease (CKD). Despite the established efficacy of these agents, the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Anemia in CKD recommends that the potential benefits of ESAs should be balanced against the potential risks of ESAs, which include hypertension and thromboembolism. Pharmacists can significantly contribute to the safe and effective use of ESAs through dose adjustments, order modifications, and continuous monitoring. This study aimed to assess the impact of a pharmacist-led ESA management protocol of hospitalized patients with CKD-related anemia. 
Methods: This study received an exemption from the Institutional Review Board. Using a quasi-experimental, retrospective comparative design, it assessed utilization of ESAs for anemia in CKD before and after the implementation of a pharmacist-driven management protocol. The pre-intervention group reflected nephrology-driven ESA management of anemia in CKD with data collected from November 01, 2023 to March 30, 2024. A locally approved protocol to provide guidance on pharmacy-led optimal initial ESA dosing, dose adjustments, monitoring parameters, and iron repletion was created with approval by nephrologists and the Pharmacy and Therapeutics Committee. All pharmacists and dialysis nurses were educated regarding the new process and protocol. The post-intervention period reflected pharmacy-driven ESA management of anemia in CKD from December 24, 2024 to February 28, 2025. Data was collected through retrospective chart review, capturing relevant patient information including ESA doses administered, transferrin saturation, ferritin levels, hemoglobin concentrations, hemodialysis status, adverse events, and pharmacist interventions. The primary outcome assessed the incidence of hemoglobin values within target range (10 g/dL – ≤ 11.5 g/dL). Secondary outcomes included the incidence of appropriate iron repletion when indicated, incidence of blood transfusion after ESA initiation and incidence of hemoglobin level > 11.5 g/dL.  
 Results: A total of 160 patients were included, 83 in the pre-intervention group and 77 in the post-intervention group. For the primary outcome, the incidence of hemoglobin values within the target range (10 g/dL – ≤ 11.5 g/dL) was 14.82% in the pre-intervention group and 21.45% in the post-intervention group (p < 0.001).  Compared with the pre-intervention group, the incidence of appropriate iron repletion when indicated was higher in the post-intervention group (17% vs. 57%; p= 0.003). The incidence of hemoglobin > 11.5 g/dL occurred in 5.51% in the pre-intervention group and 2.55% in the post intervention group (p= <0.001). Blood transfusion after ESA initiation occurred in 1.2% in the pre-intervention group and 3.9% in the post-intervention group (p= 0.276).  
Conclusion: The pharmacist-driven ESA management protocol for anemia in chronic kidney disease significantly improved the attainment of target hemoglobin levels and appropriate iron repletion. The protocol effectively prevented overcorrection of hemoglobin levels, reducing the risk of adverse cardiovascular events.