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 | Updating Practices in an Evolving IV Iron and Anemia Environment: Practical Solutions  ANNA 2007 Satellite Symposium How Are We Doing and Can We Do Better? A Team Approach to Anemia Management |
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00:00
Updating Practices in an Evolving IV Iron and Anemia Environment: Practical Solutions
Introduction
00:01
How are We Doing?
How Are We Doing and Can We Do Better? A Team Approach to Anemia Management. As we know, everybody tells us we can do better, because if you happen to be the anemia manager in your unit, you get input, a lot, from the top, if you're not meeting those targets. Some of you may even be reporting to CMS through your networks on a monthly basis, looking at your targets and what you think to do to make them better. But what I propose to you today is, that you need a team approach if you're going to improve your anemia management.
00:34
Objectives
So what we're going to do is look at the current trends, some of the controversies that are going along with the ESA information that has been coming out, look at techniques that involve looking at your entire patient, and then discuss the importance of that collaborative team approach as you deal with your anemia management on a unit-by-unit basis.
00:59
Percentage of Patients by Hb Level
Now then, we all think we are special, and we are! We all can think of those patients that we have who are so unique in our patient population, that we ought to have a dispensation from the Pope or from whomever makes the decisions about below-11 hemoglobins.
This is some of Allan Collins' data. You can get a lot more of his slides from the USRDS Web page (http://www.usrds.org), and that's where the slides that I have of his data came from. You can look across this slide and see that, from provider to provider, the Hb bars are about equal. There is almost the same number of sub-11s as there are people in target and people who are above target. So there is not great variance between the different providers.
01:50
Achieving Hb of 11 g/dL
So let's look at the probability. This is the cumulative probability of achieving a hemoglobin of above 11, again by provider, and as you see this curve going up, you can see that almost all the providers can get up to 90-plus percent of their patients above 11 g/dL. Most of them get up by the third month, but then the curve starts leveling off between the fifth and sixth month. So that kind of goes along with some slides you saw yesterday morning, that there was this constant less than 10%, 7-10% of patients, whom you never get out of that sub-11 Hb range. You really need to be looking because you really don't know which ones they are. You have to look and see what's going on with those patients, but some patients just chronically stay down there and you don't move them higher, but that other 90% of the patients you should be able to get up above 11.
02:48
Hb Greater than 14 g/dL
And we do not only get above 11, but some of us get a lot higher than 11, and that's causing some of the controversies. Some of the new research that has come out addressing that has made us critically look at the guidelines, and also has made not only the USRDS, but the federal government, look at what we're doing and how we're doing it. And so we need to look at what we're doing and how we're doing it. The unit that I am associated with is run by DaVita, even though, if you read my bio, you will see that I've been at the University of Arkansas for 30 years. First of all we were an independent, university-based unit, then RCG managed us, then Gambro bought us, and now DaVita owns us. So I've been with a lot of chains, even though my address has not changed.
So I've seen a lot of protocols, and you can say that if there was a gold medal for shooting above the targets and getting over 14 or higher on your hemoglobin, then DaVita would get the gold medal. But don't fret: shortly behind them is Fresenius and RCG, which are now the same provider. So your 2 main providers end up being the 2 groups that really overshoot that hemoglobin. And there are others that are piled up there. And then the lower 2 chains, you can see, are National (NA) and then in yellow, DCI. They have a slower climb, and just a few of their patients, 10-15% at 6 months, have a cumulative probability of getting over 14, whereas with DaVita and others you're up to 30-50% of your patients who overshoot the hemoglobin targets and get above 14. That's the probability.
If that's happening to you, then what you need to do is certainly address what your protocol looks like. And I can tell you that in many of the protocols that I look at, when a patient drops below 11, the dose of ESA is increased greatly to get them back into target. If that's happening to you, there is not that much difference between 11.1 and 10.9 and 10.8, so if your protocols call for you to increase the ESA dose, and I've seen them increase the dose from as low as about 50%, to as high - I had one just recently from a transient patient, where the increase in ESA dose was almost 1000% when they went below 11 g/dL. They followed hematocrit instead of the hemoglobin and they were following it differently. I think his hematocrit had dropped to 28%. The unit said, when I talked to them, that the patient had been a transient before several times, under 3000 units of EPO per treatment. He came back, he was on 24,300, and it was because he had been in the hospital. He had been traveling, he had been missing EPO, he dropped down. They wanted to quickly get his Hb back up, and you could do that with that kind of increase. But what you get is like stopping a car: the faster you're going, the longer it takes to stop.
So you put your anemia manager in a position to fail if they're not kind of watching, watching, and watching, because if you got those big EPO doses at the bottom, the minute the patient starts trending up, you've got to stop, or start cutting back, on your EPO, or you're going to be in the see-saw. We saw some of that on some of the slides yesterday. And if you look at some of the DOPPS data and some of the other data, the patients who do best are the patients who are kind of stable, wherever they're at. But the patients who have the worst outcomes are the ones that go sub-11, then way above, and back down, and just yo-yo. So if you're looking at protocols, or you're looking at individual patients and they're yo-yoing, that's a reason to assess your protocol, even though there are a lot of other factors that go into it, because it's a very complex process.
06:53
Federal Activity
But we do have the attention of a lot of people, and some of the people who we have the attention of is the federal government. So as the controversy on the guidelines came out, the House Ways & Means Committee met, and they focused on ESAs and they focused on bundling. There were meetings everywhere. Then GAO (Government Accounting Office) got involved with it, because they had to have some accountability there, and they're saying all services should be bundled, including injectable drugs. This is nothing new. We have been hearing all of this for years, but this is an impetus for them to go further.
The next issue is Pete Stark, Congressman Stark. He is now coming in as the Chair of the Health Subcommittee, and he has already had committee meetings. He is commenting on cost. He has given a lot of negative comments about the high doses of ESA. He is concerned about patients at risk. He has commented on subcu versus IV, and the latest thing that came across my e-mail, that some of you all may have also seen. He has essentially said, you know, that CMS better get control of this or that Congress would. And Congress is the one that approves our funding for all sorts of things, and they have the power to do that. This is kind of a wake-up call on what are we going to do. Now then, CMS has the Pay-For_Performance; injectable drugs are not necessarily included in that now, and the FDA (U.S. Food and Drug Administration) has come out, and there are black box warnings on all of the ESAs.
I know from yesterday that we have a very experienced audience here, and you can remember back like I can remember, when God and Amgen created ESAs. The next thing that was even probably as important, or more important, is that CMS funded ESAs. And at that time we could not give EPO, which was the only agent around at that time, until the patient's hemoglobin dropped below 9 g/dL. Then it was, we could give EPO if the Hb dropped below 10, and finally now, we can give EPO if the Hb drops below 11. All of that's at risk right now, and what puts that at risk is some of the practices that we have going on. So it's important that we look at what we're doing and how we are doing it, because what we are doing is jeopardizing a lot of our patients. We have to work smarter with what we have, and we need good outcomes and good protocols that we can justify. A friend of mine also said that she was online and now there are attorneys advertising that "If you've got a problem, a thrombotic event, and your hemoglobin was high, come talk to me." So everybody is trying to get a piece of the pie. So as you look at your practice, look and see if you can justify what you're doing, and what we hope to do today is give you some thoughts that you can go home with, because everybody is interested in the money as an underlying thing. But the main thing we are interested in doing is, educating and looking at our protocols and our individual patients, so that the outcomes for each patient, and the outcomes cumulatively for your unit, will improve.
10:16
Evaluating the Whole Patient
So let's look at evaluating the whole patient.
10:19
Percentage of Adult In-Center HD Patients With Mean Hb >11 g/dL
This data comes from the ESRD Clinical Performance Measures, and these are data that you've seen before, but this is the newest data. And as you look across, you can see where you dip down. Certainly in the catheter patients, only 76% of those patients have a mean hemoglobin above 11. So what could be the problem with catheter patients? Those sometimes are your sickest patients. Sometimes they are your new patients. Sometimes they are your patients who fall under the next category: when you look at the mean Kt/V, they often have a Kt/V of less than 1.2. Some of those patients whom you have on catheters just don't meet the adequacy needs and you have to address that. So adequacy and access certainly play a role in your anemia. You go on to the next box and (you see) 65%, for patients with serum albumins that are less than 3.5 g/dL. And those of you who have heard me talk before, know that I believe, and I am really going to focus a lot on this today: that our malnourished patients are some of our most iron-depleted patients. And they get really big doses of ESAs and no iron, because the indices that we look at to measure iron are all indirect indices that tend to be high in that patient population.
How long patients have been on dialysis is another factor. In your incident patients, you can see, only 64% of them have a mean hemoglobin above 11. What we do in our unit, and I suggest this to other people, we're already collecting so much data, that what I would like to do is give our doctors back information on how our incident patients are (doing). And so I now give it by patient name, by individual physician, and they want to know how long they follow that physician, so they can have the justifiable right to say, "Well, I didn't have him that long," if they were not where they were needing to be. Then I just use hemoglobin, because we have an anemia management program, and if they're on ESAs, they are also on IV iron if they need it. So I will do hemoglobin and were they getting ESAs before they start dialysis. That's just a subtle but nice way, by individual physician and individual provider, to judge how well are we doing. Are we missing patients whom we should have caught in our renal clinics and put on ESAs to start with? They should have been on ESAs a lot longer (earlier) than when they came into our unit.
12:53
Anemia Risk Factors
Now, I don't know why anemia managers have a problem, because when you look at the slide, you can see that there are almost no confounders to contribute to anemia management, so it's just cut and dry. You know that that's not all true. Iron deficiency is due to a lot of factors, and iron deficiency really affects erythropoiesis. We're not going a lot into physiology today, but if you need some physiology background you can go onto the HDCN Web pages (http://www.hdcn.com/ch/rbc/chanem. htm) and look at some of the previous talks that go in depth on physiology and erythropoiesis, and you can pull those up and look at them. But today I am going to focus on the factors that are in yellow. I am going to focus on blood loss and try to give you some insights from what goes on in our unit and what may be going on in your unit. And we're going to talk about EPO and iron balance a little bit. And some of the other things will be covered later. Then when you're looking at the coexisting medical conditions, I am really going to focus on malnutrition, but as you can see, I've already touched briefly on adequacy, and certainly bone disease causes inflammation; there is a lot of data in those previous talks that go into depth in some of these areas.
14:02
Annual Blood Loss
When you think about your patients and what's going on, I am a really strong proponent in maintenance iron, and the reason is that our patients, every time they dialyze, they lose blood. One cc of blood loss is 1 mg of iron loss, and so when you look at this study by Sargent, that's one of the newer studies on this topic, which came out in 2004, you can see that some things are about the same. But if you look at what's going on in the yellow and what's going on in the green - the yellow is the blood that's left in the circuit, and then the green is postdialysis bleeding. That certainly suggests that your PCTs (patient care technicians), your reuse techs, your nurses that are out on the floor, have some input in what's happening with those patients. If your anemia manager and your prescribers knew what was going on, then there are some things that you can find out.
Let me address first, that at our CQI meeting this month, it was brought to our attention that our adequacy numbers had dropped a little bit. Some of our patients who were on adequate doses of iron had low TSATs. So we were looking to figure out what was going on. We already had gotten new machines in our unit. We have had someone come in and actually inservice our patients, and I found out that our nurses were having some problems in priming. If you're priming a dialysis machine and you're not doing it right, there are many ways that people would say it's right, but you really should be doing it how the manufacturer recommends in most cases. But you have to look at your policies and procedures. If you leave air in those lines and blood or air in the dialyzers, and blood hits that, there is going to be more active clot. So we found out that we were having problems with priming, and so that got standardized.
You also could be looking at what was going on with postdialysis bleeding and with the blood, looking at your heparinization. If you've got somebody bleeding or if you're having a lot of blood left in the dialyzer then there could be some problems with your heparinization. How are you supposed to give heparin? You normally are supposed to give it 2 or 3 minutes before you start dialysis, so when you cannulate or when you flush your catheter, you put your heparin in there because to activate it; it needs to be protein-bound. Well, if your units are like our units, our licensed people are few and our patient care techs are more. I found out that what was happening is, that frequently patients got on the machine and their heparin was being given in their lines. So they were getting several minutes, I have no idea how long, but at least several minutes, of unheparinized blood going through your dialyzer. So that would leave blood in your circuit and that would affect your adequacy. So if you have poor adequacy and increased numbers, that could be a factor. Again, we are special in Arkansas, but if this unit was doing it and it had experienced nurses, then I am sure that that's happening in other units around the country.
Looking at postdialysis bleeding, and what they did in the study was, they actually measured and weighed the 4x4s and did a sponge count and had a weight of what was going on there, and that can be a problem. A lot of things could be going on. Perhaps your heparinization is not correct. It could be too much. Maybe your patient has newly diagnosed pulmonary emboli or atrial fib and they were started on Coumadin and you needed to back off. Maybe your patient has developed heparin-induced thrombocytopenia. You needed maybe to look at your platelet counts and see what's going on there. That could be a problem with what's going on there and that could have to do with actually your clotting. Certainly if they're having a lot of bleeding you need to look at your access and see if you're developing access stenosis and have (increased intra-access) pressure, and you need to intervene with Interventional Radiology and get an angioplasty. Maybe you're giving too much heparin, so heparin may be too much/too little, again a balance. So that's something to look at and see what's happening, and we just found that in our unit, and you may well find it in yours.
So, you can see that it (annual blood loss) is 1 g to 2 g of iron. And I would just kind of average that off to 100 mg to 200 mg of iron a month, and that should be what your patients are getting. So if your patients are getting less than that, they may very well be iron-deficient. If your patients are getting more than that, then first of all, if they're only getting it for a couple of months, maybe they just needed repletion. And sooner or later, their numbers are going to come up and you should be able to back off. But if you're consistently, month after month after month, getting a whole lot more iron than that, those are patients whom you should identify, just as you should identify your patients who are on a lot of ESAs, and go back and look. Is it that you're losing blood in your dialyzer? Is it that the patient has a GI bleed? Is it that, you know, I've had a couple of patients with dysfunctional uterine bleeding lately. Something is going on with your patient, maybe GI bleeds, that are causing them to lose iron. That's the time that you pick those things up and you go back to your patient. If you're an anemia manager and you're trying to do anemia management for 100 or 150 patients, you have to have a system in place so that that data can get to you, so that you can look at it and see what's going on, and then work with whomever your prescribers are in your practice to improve outcomes for that patient.
19:52
SGA vs. TIBC
TIBC - a lot of people don't look at iron-binding capacity. I think that it's very, very important, and I am going to show you why. This is some of Kalantar-Zadeh's data, and he correlated subjective global assessments with TIBCs (total iron binding capacity values), and you can see from the well nourished to the moderately nourished to the severely malnourished, as their malnutrition worsens, their TIBC goes down. We would like TIBCs to be above 200, and I will show the next slide and explain why, but note that for that severely malnourished group, the mean for them is definitely under 200. So why is that important?
20:36
Total Iron-Binding Capacity
Total iron-binding capacity, and it comes down to your formula, where you take the serum iron and you divide it by the total iron-binding capacity and that's how you get your transferrin saturation. Transferrin is important because it's the iron-carrying protein in the body. I call it an iron taxi. You can see from the cartoon below that it 's a molecule that will take 2 molecules of iron that can be attached to it, and then they take the iron wherever it needs to go. Transferrin picks iron up from the gut, takes it to the muscle, to the bone marrow, to the liver and the storage. Wherever it's needing to go, transferrin takes it. Transferrin is something that we don't measure directly. It's an indirect measure. From the cartoon below you can see that patients can have the same amount of serum iron, 40. But if the TIBCs were low, and so in the group that had the TIBC below 200, TSAT looked like it was fine. Their TIBC was 150, like your malnourished patient, and it showed that they had a transferrin saturation of 27%, to which we would say, "great", because we want it to be above 20. Some people like it above 25. But look at the group, then, that had a TIBC of 250. Transferrin saturation here was only 16%. So when I am assessing what's going on with my patient, I look down, and if that TIBC is above 200, I trust that my TSAT is accurate. But if my TIBC is below 200, then even if my transferrin saturation, my TSAT, is above 20 or 25, I know that it's probably lower than that, and the patient may well need iron, depending on what's going on.
22:24
Serum Ferritin and Malnutrition
Then on to ferritin, this again is Kalantar-Zadeh's work a little bit later, in publication, and they're looking at serum ferritin. And you can see from the normal to the moderate to the severe malnutrition, that the ferritins go up. If you look at the severely malnourished patients, you can see that the ferritin goes all the way up to 1300 to 1400 ng/mL, and even the lower range hits in there around 800. Now, remember when we're looking at serum ferritin, serum ferritin is a molecule where, kind of, you take one iron and put it into storage and a serum ferritin comes out. Serum ferritin has very little iron. Actually all of the transferrin in the body has about 3 mg of iron in it. And so it's again an indirect measure - it's not a direct measure of iron stores but it's an indirect measure. So patients who are inflamed, patients who are infected, patients who are malnourished, may well have high ferritins. Patients with liver disease have higher ferritin. So there are lots and lots of reasons for high ferritins. I tell my patients when their ferritins are high, it's like your body is screaming at me that something is wrong. I may not be able to figure out what it is, but something is going on with that patient.
You're going to find, if you really start looking at ferritins, that there are a lot of your patients who just live there. They live with ferritins that are somewhere in the 600-800, all the way up to the 1000-1200, range. And sometimes you can figure out what's going on and sometimes you can't. The ones who you should be looking at, the ones you really need to be attuned to, are the ones who have a ferritin of X, and then all of a sudden it jumps really high up. Because if you go back and even look at your hospitalizations, usually your high ferritin will precede a hospitalization if you've gotten your blood levels right before that. So it's an interesting thing for anemia managers to go back and look and say, "What's the trend on this patient and what's going on?" So I will tell you some of the things that I found with high ferritins in my patients within the last 6 months. I found a couple of patients with really bad abscessed teeth. We have identified a number of malignancies. I've found a renal cell cancer, a pancreatic cancer, and a breast cancer, within probably the last 9 months. I've had histories where I have patients with increased illicit drug use whom I've talked about before. So if they're on the same degree of illicit drug use, you don't notice it, but if it goes up, then you might. So lots of things. So it means something, and it's one of those things that it's great to kind of talk to a patient, and decide what's going on with that patient and try to figure it out. But if you looked and it's not active infection, then you might well want to try iron and see if it works. If it doesn't work, you go back and look for infection again.
25:43
Team Approach
So how can you do that? you're one anemia manager. How can you make a difference for anywhere from 50 to 150 to 200 patients, that some of you might well be following. It really takes a team approach. And these are a couple of articles, and I also would refer you to Debbie Brouwer's article. All of them are in the Nephrology Nursing Journal and a good resource. And you need to be thinking: if you're going to be changing your protocols and looking at things, you too could be an author for the Nephrology Nursing Journal. So think about what you're doing. You may well even be able to set it up as a research project depending on what you're doing, and get one of those nice awards that they have been giving out at the ANNA meeting.
26:30
A Collaborative Approach to Implementing Changes
So here's what they did. This is Pruett's article, and it has just come out in the 2007 Nephrology Nursing Journal. They looked at a collaborative approach to see what they could do to implement change and improve their outcomes. And they took their area educators and they identified different things in the literature, looked at all the updates, looked at their clinical guidelines and what changes needed to be made. Their nurses obtained information on the different iron products, looked at iron dosing practices, and tracked patient data, to see what was going on. Their anemia managers all were educated. They had home courses to do, and in-services for, like 6 months, that they did, and they reported back. And then there was accountability through the clinical manager and the medical director, to make sure that the new protocols were taking place and implemented.
27:29
Initial Changes in Anemia Management Parameters
What were their outcomes? This was after 6 months of initiating the change. Their hemoglobins improved by over 11%. Their TSATs came up almost 30%. Their serum ferritins went down, the ones that were in the 100 to 700 range just slightly, and their serum ferritins above 700 actually increased a little bit. And that could be, that some of those patients who needed iron actually got it. And Dr. Amerling will talk about the DRIVE study in a little bit and address some of the higher ferritin issues. Their percentage of patients who received iron increased 32%. So for 32% more patients who were getting iron, that percentage of serum ferritin above 700 is really fairly insignificant. Their ESA use went down 21% and their IV iron use went up again, almost 30%. Now, we're not here to say to use more iron and use less EPO, or use more EPO and less iron. It's a balance. I tell patients it's like making chocolate chip cookies, and I tell staff that too. It's really hard to make chocolate chip cookies if you don't have chocolate chips. It's really hard for the body to make red blood cells if it doesn't have iron, and iron is important on around day 19 of erythropoiesis, and so everyday is day 19 for some cell, and if you don't have iron available on that day, it will not get into the cell later. So it's highly important.
29:12
Anemia Management Team Improves Hb Outcomes
There is also an article from the 2003 journal by Krishnan, and they had a team approach also. What they were trying to do with their team, again, is to improve their outcomes. And by having the team in place, it resulted in a 30% reduction in their patients with sub-11 hemoglobins. The head of the team was the anemia manager, and they integrated their ESA and iron protocols. And that's what I find when I talk to, especially, novice anemia managers. You can have very experienced nurses, but if they're novice in the anemia management area, it's pretty overwhelming, and they focus so much on the ESA that they forget about the iron. And you really have to have a way that you can look at both of them together. And then, optimally, the team that you set up gets all the way back down to, as I said, the reuse tech, if you're using them, and your PCT, and your nurses, to find those patients, if you don't do it for everybody, especially the sub-11 group, to identify what's going on with those patients, so that you can clinically assess what's happening with them. You will put everybody, you, the patients, and your programs, in a win-win situation.
30:27
The Anemia Manager
I think all nephrology nurses, but anemia managers in particular, are an under-appreciated commodity in the dialysis unit sometimes. They have a job that's extremely difficult and they're getting input and advice from everybody and their brother. And the goal is to try to achieve that balance of the appropriate dose of ESA and the appropriate dose of iron. And a really good anemia manager may be the first person to know that your patient is in trouble. And there is something very satisfying as a nurse and as a patient advocate to be the one to point out to whomever. It's not "I am better than you are" but that you're the one that ferreted out that this patient is in trouble. You identify what's going on and correct it. What a difference you can make in the patient's life! It's a just very neat experience. And if you're the anemia manager, you may be the very first one to point out that, or to notice that, something is going astray. But to do that, if you can empower not only that anemia manager but everybody, all the way down to the patient level, like we used to do back in the 1980s and early 1990s when we were developing quality assurance teams and CQI teams, all the players had a voice. You can have empowerment from your upper echelon all the way down to your PCT, to enrich their jobs, empower them, get them involved with your patients in what's going on, and get that information out. And your patients' lives will improve, and the inordinate amount of pressure to reduce the sub-11s will decrease. Because that anemia manager needs support. So if you're not the anemia manager, when you go home and you see your anemia manager, just give him or her a great big hug, because they have an overwhelming job, and we need to be as kind and supportive to them as we can be.
32:28
Conclusions
In conclusion, our outcomes, those anemia outcomes, really require the balance that I talked about before. It involves looking at that whole patient, because there are so many factors that play into it, and you find really odd things that stick out in your mind that need to be in that equation when you're making treatment decisions. You need to assess factors such as blood loss, malnutrition, high doses of ESAs, high doses of iron, and what's happening with your incident patients. Look at those protocols which Peter is going to focus on and ask, "Are they appropriate, do they need to be tweaked?" And figure out who you need on your team to be successful, and how to facilitate the changes that you need in your unit to accomplish a team approach that will help not only you but your patients.
References
- US Department of Health and Human Services.. 2005 Annual Report. ESRD Clinical Performance Measures Project 2005 Annual Report: ESRD CPM Project
- Collins AJ, Dunning S, Zhang R, and Gilbertson D.. Is overshooting the target hemoglobin range related to the practice of dialysis provider? USRDS Presentations, Am Soc Nephrol., 2006
- NKF-K/DOQI. IV. NKF-K/DOQI Clinical Practice Guidelines for Anemia of Chronic Kidney Disease: update 2000. Am J Kidney Dis. 2001 Jan;37(1 Suppl 1):S182-238.
- Kalantar-Zadeh K, Rodriguez RA, Humphreys MH. Association between serum ferritin and measures of inflammation, nutrition and iron in haemodialysis patients. Nephrol Dial Transplant. 2004 Jan;19(1):141-9.
- Kalantar-Zadeh K, Kleiner M, Dunne E, Ahern K, Nelson M, Koslowe R, Luft FC. Total iron-binding capacity-estimated transferrin correlates with the nutritional subjective global assessment in hemodialysis patients. Am J Kidney Dis. 1998 Feb;31(2):263-72.
- Krishnan M, Adams E. Operationalizing anemia management: organizing the program and coordinating the team. Nephrol Nurs J. 2003 Oct;30(5):567-70.
- Pruett B, Johnson S, O'Keefe N. Improving IV iron and anemia management in the hemodialysis setting: a collaborative CQI approach. Nephrol Nurs J. 2007 Mar-Apr;34(2):206-13.
- Sargent JA, Acchiardo SR. Iron requirements in hemodialysis. Blood Purif. 2004;22(1):112-23.
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