Effects of novel anemia nurse manager program on hemodialysis: a retrospective study from Qatar

Introduction: Anemia management in dialysis is challenging. Keeping hemoglobin levels within a tight range is difficult. A new program (anemia nurse manager [ANM]) was started for better anemia management. This study aimed to compare traditional anemia management with the new ANM model regarding the achievement of better hemoglobin targets (range, 10–12 g/dL), avoidance of extreme hemoglobin levels ( < 9 or >13 g/dL), and evaluation of the cost-effectiveness of the new model. Methods: This retrospective observational study compared traditional anemia management with management involving our new ANM model. Patients on hemodialysis in all ambulatory dialysis clinics in Qatar were included. The study included three phases: phase 1 (observation): June 2015 to August 2015, 460 patients; phase 2 (pilot): September 2015 to May 2016, 211 patients; and phase 3 (expansion in two phases): June 2016 to February 2017 and October 2017 to June 2018, 610 patients. Hemoglobin, iron saturation, and ferritin were evaluated according to the protocol. Results: In this study, 55% of the patients achieved the target hemoglobin in phase 1 compared with 75% in phase 2 (p = 0.0007). The hemoglobin level within the target range was sustained at 72% ± 5% of patients in phase 3. The achievement rate of the target hemoglobin level increased from 56% (May 2015) to 72% (July 2018) (p < 0.001). The proportion of patients with extreme hemoglobin declined from 10.7% in phase 1 to 6.4% in phase 2 and sustained at 8% afterward. Reducing the doses of erythropoietin stimulating agents, owing to the use of the ANM model, saved costs by approximately 11%. Conclusions: The ANM model was able to achieve and maintain hemoglobin levels within the target range and decrease extreme hemoglobin levels. These outcomes improved patient care by avoiding high hemoglobin (increase thrombosis, cancer recurrence, stroke, and death) and low hemoglobin (weakness, poor quality of life, and need for transfusion) levels. The ANM model was cost effective even after including the salaries of nurses. This model can be considered in other aspects of patient care in dialysis.

Hematologic complications of immune checkpoint inhibitors

Immune checkpoint inhibitors are a class of anti-neoplastic therapies that unleash immune cells to kill malignant cells. There are currently 7 medications FDA-approved for the treatment of 14 solid tumors and 2 hematological malignancies. These medications commonly cause immune-related adverse effects due to overactive T lymphocytes, autoantibody production, and/or cytokine dysregulation. Hematological toxicities are rare and of uncertain mechanism, and therefore management is often based on experiences with familiar conditions involving these perturbed immune responses, such as autoimmune hemolytic anemia, immune thrombocytopenia, and idiopathic aplastic anemia. Management is challenging because one must attend to the hematological toxicity while simultaneously attending to the malignancy, with the imperative that effective cancer therapy be maintained or minimally interrupted if possible. The purpose of this review is to assist clinicians by providing a clinical and pathophysiological framework in which to view these problems.

Perioperative Management of Patients for Whom Transfusion Is Not an Option

This article reviews the management of patients requesting or requiring surgery without transfusion, including patient identification and informed consent, determining preoperative target hemoglobin and anemia management, and intraoperative and postoperative blood conservation techniques.