Effects of changes in adult erythropoietin dosing guidelines on erythropoietin dosing practices, anemia, and blood transfusion in children on hemodialysis: findings from North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS)

  • Sarah A. TwichellEmail author
  • Elizabeth A. K. Hunt
  • Karen Martz
  • Michael J. G. Somers
  • on behalf of the NAPRTCS investigators
Original Article
Part of the following topical collections:
  1. What's New in Dialysis



While adult hemodialysis (HD) patients have increased morbidity with higher target hemoglobin levels, similar findings have not been demonstrated in pediatric patients. We evaluated changes in transfusions, anemia frequency, and erythropoietin (epo) dosing among pediatric HD patients before, during, and after implementation of federal dialysis payment policies regarding epo dosing for adult HD patients.


This is a retrospective cohort study of pediatric HD patients enrolled in NAPRTCS. We evaluated need for transfusion, anemia, median hemoglobin, and median epo dose 6 months after starting HD in 3 eras: baseline (2003–2007), implementation (2008–2011), and post implementation (2012–2016). We used multivariate logistic regression models to evaluate potential differences in transfusion across the eras.


Six months after dialysis initiation, 12.6% of patients required transfusion pre-implementation, 17.9% during implementation, and 15.5% post implementation. Anemia occurred in 17.4% of patients pre, 23.5% during, and 23.8% post implementation, with median hemoglobin levels of 11.9 g/dL pre, 11 g/dL during, and 11 g/dL post implementation. Epo use was high across all 3 eras, but epo dosing decreased during and post implementation, despite more anemia during these periods. Odds of transfusion in implementation era compared with pre-implementation was 1.75 (95% CI 1.11–2.77) and odds of transfusion in post implementation era compared with pre was 1.19 (95% CI 0.71–1.98), controlling for age, race, gender, and prior transplant status.


During and following implementation of adult epo dosing guidelines, transfusion and anemia frequency increased in pediatric HD patients. Ideal target hemoglobin levels for pediatric dialysis patients warrant further study.


Anemia Hemodialysis Erythropoietin Transfusion Children 



We would like to acknowledge the NAPRTCS study group and participants for making this research possible.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Supplementary material

467_2019_4359_MOESM1_ESM.docx (17 kb)
ESM 1 (DOCX 17 kb)


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Copyright information

© IPNA 2019

Authors and Affiliations

  1. 1.Department of Pediatrics, Robert Larner, M.D. College of Medicine and the University of Vermont Children’s HospitalThe University of VermontBurlingtonUSA
  2. 2.EMMES CorporationRockvilleUSA
  3. 3.Division of NephrologyBoston Children’s HospitalBostonUSA
  4. 4.Department of PediatricsHarvard Medical SchoolBostonUSA

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