CLINICAL OUTCOMES AFTER ERYTHROPOIESIS-STIMULATING AGENT THERAPY IN HEMODIALYSIS PATIENTS AMONG THAILAND REIMBURSEMENTS

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Abstract Title *

CLINICAL OUTCOMES AFTER ERYTHROPOIESIS-STIMULATING AGENT THERAPY IN HEMODIALYSIS PATIENTS AMONG THAILAND REIMBURSEMENTS

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Co-author 1

Supoj Chueachinda menn.fattyacid123@gmail.com Thammasat University Medicine Pathumthani Thailand *

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Pichaya Tantiyavarong ball.tanti@gmail.com Thammasat University Medicine Pathumthani Thailand -

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Introduction

Anemia is prevalent among hemodialysis (HD) patients and is associated with cardiovascular events and mortality. Erythropoiesis-stimulating agents (ESA) are essential for management; however, access varies across healthcare schemes, and regulatory constraints may impede achieving target hemoglobin (Hb) levels. This study aimed to compare clinical outcomes across different ESA reimbursement policies in Thailand.

Methods

This retrospective cohort study was conducted on incident HD patients receiving ESA at Thammasat University Hospital between January 2011 and December 2024. ESA therapy was categorized into two approaches: “Protocol-based (PB)” (Social Security and Universal Coverage Schemes), which restricts the use of ESA, and “Individualized-based (IB)” (Government or State Enterprise Officer Scheme). The primary composite outcome included death, non-fatal myocardial infarction (MI), non-fatal stroke, and congestive heart failure (CHF). Secondary outcomes included the percentage achieving Hb target (>10 g/dL), ESA and iron doses and adverse events.

Results

Figure 1 The Kaplan–Meier survival compares composite clinical outcomes between the IB group and PB group Figure 2 The Kaplan–Meier survival compares death between the IB group and PB group Figure 3 The Kaplan–Meier survival compares MI between the IB group and PB Figure 4 The Kaplan–Meier survival compares stroke between the IB group and PB group Figure 5 The Kaplan–Meier survival compares CHF between the IB group and PB group Figure 6 Percentage achieving Hb target (10 gdl) between the IB group and PB group A total of 261 incident HD patients were included (median follow-up 5.7 years). The mean (SD) age was 64.3 (15.2) and 49% were male. The primary outcome occurred in 50 of 105 patients (47.6%) in the PB group and 72 of 156 patients (46.1%) in the IB group (HR 1.49, 95% CI 0.99-2.28, p=0.07). The PB group showed a higher risk of non-fatal MI (HR 2.4, 95% CI 1.19–4.84, p=0.015) and CHF (HR 1.94, 95% CI 1.02–3.70, p=0.04). The percentage of patients achieving Hb target was significantly lower in the PB group (62.9% vs. 71.5%, p<0.01). ESA and Intravenous iron doses and adverse events were similar in both groups.

Conclusion

The protocol-based approach limits ESA doses, resulting in lower Hb levels and a trend toward more cardiovascular events. These findings highlight the impact of reimbursement policies on the effectiveness of ESA therapy in Thailand.

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