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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">Anemia is an important and almost universal complication of advanced chronic kidney disease &#40;CKD&#41;&#46; Since the introduction of recombinant human erythropoietin in 1989&#44; several studies have reported that erythropoietin-stimulating agents &#40;ESAs&#41; increase hemoglobin &#40;Hb&#41; levels&#44; improve quality of life&#44; and reduce requirements for blood transfusion&#46; However&#44; the therapeutic Hb target remains a controversial issue&#46; Three studies in predialysis patients &#40;Correction of Anemia with Epoetin Alfa in Chronic Kidney Disease &#40;CHOIR&#41;&#44; Normalization of Hemoglobin Level in Patients with Chronic Kidney Disease and Anemia &#40;CREATE&#41;&#44; and A Trial of Darbepoetin Alfa in Type 2 Diabetes and Chronic Kidney Disease &#40;TREAT&#41; reported that normalization of Hb was associated with no benefit in terms of cardiovascular morbidity and mortality&#44; and with an increased risk of stroke and cancer in patients with a history or current malignancy&#46;<span class="elsevierStyleSup">1-3</span> A recent study by Coyne demonstrated that in HD patients with ischemic heart disease or heart failure&#44; higher Hb &#40;13-15g&#47;dL&#41; could increase nonfatal myocardial infarcts&#44; deaths&#44; and has no effect in improving quality of life compared to those with Hb of 11g&#47;dL&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">Since 1997&#44; several clinical practice guidelines for the management of anemia of CKD have been published&#46; The 2007 version of the National Kidney Foundation-Kidney Disease Quality Outcomes Initiative &#40;NKF-KDOQI&#41; suggested a Hb target between 11 and 12g&#47;dL&#44; while avoiding levels above 13g&#47;dL&#46;<span class="elsevierStyleSup">5</span> Two years later&#44; the Anemia Working Group of European Renal Best Practice &#40;ERBP&#41; endorsed these recommendations&#46;<span class="elsevierStyleSup">6</span> In 2008&#44; the Anemia Working Group of the Latin American Society of Nephrology and Hypertension &#40;SLANH&#41; &#40;RPCA-ERC&#47;SLANH&#41; recommended to maintain Hb levels between 10&#46;5 and 12g&#47;dL&#44; ferritin levels between 200 and 500&#956;g&#47;L and transferrin saturation &#40;TSAT&#41; levels between 30 and 40&#37;&#46;<span class="elsevierStyleSup">7</span> Finally&#44; the recently published Kidney Disease Improving Global Outcomes &#40;KDIGO&#41; anemia guidelines suggested to consider starting ESAs therapy in iron replete HD patients when the Hb levels are between 9&#46;0 and 10&#46;0g&#47;dL&#44; and to maintain it at &#8804;11&#46;5g&#47;dL&#46; It also recommended to individualize therapy by taking into consideration the balance between benefits of reducing blood transfusions and anemia-related symptoms and risks associated with ESAs therapy&#46;<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara">In the Latin American &#40;LA&#41; region&#44; little is known about anemia management in dialysis patients&#46; Interestingly&#44; LA patient populations consist of a variety of races that live anywhere from sea level to mountainous regions with altitudes as high as 13&#44;000 feet&#46; Furthermore&#44; there are important socioeconomic disparities and health care systems that vary from country to country&#46; These and other factors may influence anemia management in CKD patients resulting in variations in Hb levels&#46;</p><p class="elsevierStylePara">The Latin American Society of Nephrology and Hypertension &#40;SLANH&#41; survey collected data of patients receiving kidney replacement therapy in 20 LA countries&#46; In its latest report&#44; 147&#44;158 patients were receiving chronic HD in the region&#46;<span class="elsevierStyleSup">9</span> However&#44; scant anemia management data are available&#46; Therefore&#44; under the auspices of the SLANH&#44; the Latin American Anemia Committee was established to specifically address this issue&#46;</p><p class="elsevierStylePara">In this paper&#44; we present the first report of the SLANH&#8217;s anemia survey with data on 9&#44;025 HD patients from 16 LA countries&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">METHODS</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">In this cross-sectional study&#44; a survey developed by the Anemia Committee was sent to SLANH&#8217;s affiliated national societies of nephrology and was then distributed to the different local dialysis units who were independent&#44; non-chain owned&#46; Nephrologists were requested to fill out the survey with anemia management data collected between September and December 2009&#44; although this period had to be extended through March 2010&#46;</p><p class="elsevierStylePara">Inclusion criteria were adult &#40;&#8805;18 years of age&#41; patients receiving chronic HD for at least 3 months&#46; Data collected included age&#44; gender&#44; cause of CKD&#44; dry weight&#44; last Kt&#47;V&#44; time on HD&#44; type of ESA used&#44; total weekly dose&#44; route of administration &#91;intravenous &#40;IV&#41; or subcutaneous &#40;SC&#41;&#93;&#44; type of IV iron preparation used&#44; total monthly dose&#44; last Hb&#44; ferritin&#44; and TSAT &#40;during the data collection period&#41;&#44; and blood transfusion use during the prior two months&#46;</p><p class="elsevierStylePara">Databases of each country were validated and merged into a single database&#46; Missing and out-of-range values were excluded&#46; Acceptable ranges were as follows&#58; Hb&#58; 3-16g&#47;dL&#44; ferritin&#58; &#60;5&#44;000&#181;g&#47;L&#44; TSAT&#58; 5-100&#37;&#44; time on HD&#58; 0&#46;3-28 years&#44; Kt&#47;V&#58; 0&#46;5-3&#46;5&#44; weekly ESA dose &#40;erythropoietin-&#945; or &#946;&#41;&#58; 1&#44;000-30&#44;000IU&#44; and monthly IV iron dose&#58; 50-2&#44;400mg&#46; Selection of these ranges was based on the distribution of data and clinical judgment&#46; Descriptive statistics were used to analyze patient and anemia management data&#46; T-test or ANOVA were used for continuous variables and chi square test for categorical variables&#46; A p-value of &#60;0&#46;05 was considered statistically significant&#46; For some analyses&#44; patients were stratified according to Hb level &#60;10&#46;5g&#47;dL &#40;low&#41;&#44; 10&#46;5-12&#46;0g&#47;dL &#40;target range&#41;&#44; and &#62;12&#46;0g&#47;dL &#40;high&#41;&#46; Multivariate conditional logistic regression analysis was performed to determine factors associated with Hb&#8805;10&#46;5g&#47;dL versus &#8804;10&#46;5g&#47;dL&#46;</p><p class="elsevierStylePara">Independent variables were entered by the stepwise forward method and included age&#44; gender&#44; ferritin&#44; TSAT and Kt&#47;V levels&#46; All statistical analyses were performed with the Statistical Package for Social Sciences SPSS&#44; version 17&#44; Chicago&#44; IL&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Baseline patient characteristics</span></p><p class="elsevierStylePara">A total of 171 surveys from the same number of unit hemodialysis centers were received&#46; From those surveys&#44; 134 had all inclusion criteria and a total of 9&#44;025 chronic HD patients from 16 LA countries were incorporated in the analysis&#46; Baseline patient characteristics are shown in Table 1&#46; Mean age of the patients was 57&#46;4&#177;15&#46;7 years and 58&#37; were men&#46; Causes of CKD were arterial hypertension &#40;40&#46;8&#37;&#41;&#44; diabetes mellitus &#40;29&#46;7&#37;&#41;&#44; glomerular disease &#40;18&#46;1&#37;&#41; and other causes &#40;11&#37;&#41;&#46; Mean time in HD was 3&#46;9&#177;3&#46;8 years&#46; Brazil&#44; Chile&#44; and Argentina accounted for two-thirds of the patients &#40;34&#46;1&#37;&#44; 17&#46;5&#37;&#44; and 15&#46;2&#37;&#44; respectively&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Anemia management</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">Results of anemia management are shown in Table 2&#46; The majority of patients &#40;84&#46;7&#37;&#41; were receiving some type of ESA during the study period&#46; Erythropoietin-&#945; and erythropoietin-&#946; were used in 73&#37; and 10&#46;1&#37; of the patients&#46; The median weekly dose for erythropoietin-&#945; was 6&#44;000IU with SC administration and 11&#44;000IU with IV administration and the corresponding average SC weekly doses were 7&#44;330&#177;4&#44;276UI&#47;week or &#40;118&#177;75UI&#47;Kg&#47;week&#41; and 10&#44;622&#177;6&#44;072UI&#47;week &#40;171&#177;104UI&#47;Kg&#47;week&#41;&#44; respectively &#40;p&#61;0&#46;0001&#41;&#46; ESAs were more often administered by the SC route &#40;83&#46;9&#37;&#41;&#46;</p><p class="elsevierStylePara">About two thirds &#40;68&#46;3&#37;&#41; of the patients were receiving IV iron&#46; Iron saccharate and low molecular weight iron dextran were used in 56&#46;3&#37; and 10&#37; of patients&#44; respectively&#46; The median iron monthly dose for both iron preparations was 200mg&#44; whereas the mean monthly doses for iron sacharate were 317&#177;243mg &#40;range 50-1&#44;400mg&#47;month&#41; and for the low molecular iron weight iron dextran 318&#177;230mg &#40;range 50-1&#44;000mg&#47;month&#41;&#46; No significant differences in mean iron doses were observed between male and females&#44; or between patients with or without diabetes&#46; Blood transfusions in the prior two months were given to 8&#46;2&#37; of patients&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Hemoglobin and iron values</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">Mean &#40;&#177;SD&#41; values of Hb &#40;n&#61;9&#44;025&#41;&#44; ferritin &#40;n&#61;7&#44;915&#41;&#44; and TSAT &#40;n&#61;5&#44;705&#41; were 10&#46;5&#177;1&#46;8g&#47;L&#44; 570&#177;539mg&#47;L&#44; and 29&#46;8&#177;15&#37;&#44; respectively&#46; Most of the women &#40;52&#37;&#41; had Hb&#8804;10&#46;5g&#47;dL&#44; meanwhile 58&#37; of the men had Hb&#8805;10&#46;5g&#47;dL &#40;p&#61;0&#46;0001&#41;&#46; However&#44; ESA doses were higher in women &#40;137U&#47;Kg&#47;week&#41; than in men &#40;116U&#47;Kg&#47;week&#41;&#44; &#40;p&#61;0&#46;0001&#41;&#46;</p><p class="elsevierStylePara">Only 32&#46;7&#37; of patients were within the Hb target recommended by the RPCA-ERC&#47;SLANH&#44; the remaining 46&#46;3&#37; and 21&#46;1&#37; of patients had Hb levels below &#40;&#60;10&#46;5g&#47;dL&#41; or above &#40;&#62;12&#46;0g&#47;dL&#41; the recommended target&#44; respectively&#46; Figure 1 shows the distribution of Hb levels by the participating countries&#46; Chile&#44; Paraguay and Venezuela were the countries with the lowest mean Hb values &#40;&#60;10&#46;5g&#47;dL&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Factors associated with hemoglobin levels</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">Table 3 depicts univariate associations between several anemia management variables and Hb levels within and outside the recommended target&#46; A higher TSAT was associated with <br></br>the highest Hb levels&#46; Additionally&#44; higher ESA and IV iron doses were associated with Hb levels below the recommended target&#46; Among patients with Hb level between 10&#46;5-12g&#47;dL&#44; 62&#46;4&#37; had TSAT&#8805;25&#37;&#44; whereas only 46&#46;6&#37; of those with Hb levels &#60;10&#46;5g&#47;dL had a TSAT&#8804;25&#37; &#40;p&#61;0&#46;0001&#41;&#46; Moreover&#44; in the group with Hb&#60;10&#46;5g&#47;dL&#44; the ESAs were prescribed in 84&#44;3&#37; and iron IV in 68&#46;3&#37; of the patients&#46; Further variables&#44; such as ferritin and Kt&#47;V&#44; were not significantly different among the Hb groups&#46; The results of a multivariate logistic regression analysis demonstrated that the variables independently associated with Hb levels &#60;10&#46;5g&#47;dL were&#58; age&#8804;50 years &#40;RR&#61;1&#46;17&#44; 95&#37;CI&#61;1&#46;04-1&#46;32&#44; p&#60;0&#46;01&#41;&#44; female &#40;RR&#61;1&#46;37&#44; 95&#37;CI&#61;1&#46;22-1&#46;54&#44; p&#60;0&#46;001&#41;&#44; and TSAT&#8804;25&#37; &#40;RR&#61;1&#46;43&#44; 95&#37;CI&#61;1&#46;27-1&#46;6&#44; p&#60;0&#46;0001&#41; &#40;data not shown&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">The main findings of this first report of the SLANH&#8217;s anemia survey can be summarized as follows&#58; a&#41; the majority of patients attending independent&#44; not-chain owned chronic HD facilities were receiving an ESA&#59; b&#41; erythropoietin &#945; was more frequently used&#44; at a median weekly dose of 6&#44;000IU SC and 11&#44;000IU IV&#59; c&#41; SC was the preferred route of ESA administration&#59; d&#41; two-thirds of patients were receiving IV iron&#59; e&#41; mean values of Hb&#44; ferritin&#44; and TSAT were 10&#46;5&#177;1&#46;8g&#47;dL&#44; 570&#177;539&#956;g&#47;L&#44; and 29&#46;8&#37;&#177;15&#37;&#44; respectively&#59; f&#41; only one-third of patients were within the SLANH&#8217;s recommended Hb target of 10&#46;5-12&#46;0g&#47;dL&#44; and nearly half of patients had Hb values below 10&#46;5g&#47;dL&#59; g&#41; age&#8804;50 years&#44; female&#44; and TSAT&#8804;25&#37; were independently associated with having a Hb level below the recommended target&#46;</p><p class="elsevierStylePara">Published anemia data in the management of chronic HD patients in LA is scarce&#46; Despite important limitations&#44; possible sources of information are individual Register from local LA nephrological societies&#46; The 2008 Brazilian Society of Nephrology&#8217;s Dialysis Census Report reported that 83&#37; of chronic HD patients were receiving an ESA and 53&#46;5&#37; an iron preparation&#46;<span class="elsevierStyleSup">10</span> Additionally&#44; 47&#46;7&#37; had Hb levels &#60;11g&#47;dL&#46; Another study of 32&#44;136 Brazilian chronic HD patients reported that being male and having an age of &#60;65 years&#44; diabetic CKD&#44; or an arteriovenous fistula&#44; were independently associated with ESAs use&#46;<span class="elsevierStyleSup">11</span></p><p class="elsevierStylePara">The 2009 Uruguayan Society of Nephrology Register reported that 94&#37; of chronic HD patients were receiving an ESA and 65&#37; iron&#59; it also reported that 62&#46;3&#37; of patients and 19&#46;5&#37; had Hb levels between 10&#46;5-12g&#47;dL and &#60;10g&#47;dL&#44; respectively&#46;<span class="elsevierStyleSup">12</span> The 2010 Register from the Chilean Society of Nephrology reported that&#44; among 14&#44;462 chronic HD patients&#44; 54&#46;6&#37; had a hematocrit &#60;30&#37;&#44; and that 42&#46;5&#37; were receiving ESA treatment and 51&#46;7&#37; IV iron&#46;<span class="elsevierStyleSup">13</span> Overall&#44; these data demonstrate that there is significant variability in anemia management among the different LA countries&#46;</p><p class="elsevierStylePara">Comparison of our results with those of other non-LA countries is difficult to assess in part due to variations of Hb target levels in chronic HD patients in different clinical practice guidelines&#46;<span class="elsevierStyleSup">8&#44;14&#44;15</span> This SLANH&#8217;s anemia survey is a first attempt to try to elucidate the status of anemia management among LA chronic HD patients&#46; We found that the median Hb level was 10&#46;5g&#47;dL and that only 34&#37; of patients had Hb levels within the target recommended by the RPCA-ERC&#47;SLANH&#46; However&#44; a subsequent statistical analysis showed that 61&#46;4&#37; of patients had Hb levels above 10g&#47;dL&#46; Surprisingly&#44; 84&#37; of the patients were receiving an ESA and 68&#37; IV iron treatment&#46;</p><p class="elsevierStylePara">Regarding ESA doses&#44; the mean SC dose of erythropoietin &#945; was 7&#44;330IU&#47;week and in the IV administration was 10&#44;662IU&#47;week to achieve median Hb levels of 10&#46;5g&#47;dL in slightly over one-third of patients&#46; Most other Society Registers do not report the discrimination between IV and SC ESAs doses&#46; The 2010 UK Annual Renal Register reported a mean ESA dose of 9&#44;507IU&#47;week and that 85&#37; of patients had Hb levels &#8805;10g&#47;dL&#44; with the median level being 11&#46;6g&#47;dL&#46;<span class="elsevierStyleSup">16</span> The 2012 US Renal Data Report shows that by the end of 2010&#44; the mean ESA dose was 15&#44;829IU&#47;week with an achieved mean Hb level of 11&#46;3g&#47;dL&#46; Roughly&#44; two-thirds of patients had Hb levels in the 10-12g&#47;dL range&#46; Additionally&#44; the highest doses of IV iron of 2&#44;700 mg or more were present in 24&#37; of patients who were treated jointly with ESAs&#46;<span class="elsevierStyleSup">17</span></p><p class="elsevierStylePara">In a recent report from Japan&#44; of 1&#44;622 patients the mean Hb was 10&#46;3g&#47;dL&#46; The majority were treated with ESAs &#40;82&#46;2&#37;&#41;&#44; but only 54&#37; of the patients had Hb levels within the target recommended by the Japanese guidelines&#46; The mean ESAs doses administered by IV were 4&#44;645IU&#47;week&#46;<span class="elsevierStyleSup">18</span></p><p class="elsevierStylePara">Our findings also demonstrate that the RPCA-ERC&#47;SLANH recommended levels of TSAT and ferritin &#40;&#62;25&#37; and &#8805;200&#956;g&#47;L&#44; respectively&#41; were associated with the highest Hb levels&#46; We also found a negative association between ferritin and TSAT with ESAs and iron IV doses&#46; The association between the low Hb and TSAT&#8804;25&#37; suggests that a functional iron deficiency could be present in a high percentage of patients&#46; However&#44; the low percentage of patients that were tested for TSAT &#40;63&#37;&#41; suggests that the assessment for a complete iron status testing is necessary for the adequate control of anemia in HD patients in LA&#46; The mechanism of poor anemia control detected in women&#44; even though receiving higher weight adjusted ESA doses&#44; was probably due to the fact that women were iron undertreated when compared to men &#40;47&#37; vs 52&#37;&#44; respectively&#41;&#46;</p><p class="elsevierStylePara">We also found that ESAs and iron IV doses were higher for patients with low Hb levels which could suggest ESA hyporesponsiveness&#46; Multivariable logistic regression analysis demonstrated that the independent variables associated with Hb level &#60;10&#46;5g&#47;dL were female gender&#44; TSAT&#8804;25&#37;&#44; and age&#8804;50 years&#46; Female gender and low TSAT are known as factors for ESA hyporesponsiveness&#46;<span class="elsevierStyleSup">19&#44;20</span> The variable age&#8804;50 year is probably because our HD population is younger than that reported in other populations&#46;</p><p class="elsevierStylePara">The inter-variation in the Hb levels between LA countries could be due to several causes&#44; such as anemia treatment &#40;including laboratory test and drugs&#41; which represents an important cost for the diverse health care systems&#46; This could reflect a potential restriction in anemia management practices&#44; not only for the prescription of inappropriate doses&#44; but also for the frequency of administration&#46;</p><p class="elsevierStylePara">Our study has several limitations&#46; It is cross-sectional with all the statistical limitations associated with this type of study design&#46; We only selected non-chain owned HD units&#44; primarily because there was an ease of access to obtain the data&#46; Since participation in the study was voluntary&#44; data from some countries were very limited&#44; and also some of the participating countries have data from only one HD unit&#46; The survey was not designed to evaluate the effectiveness of any of the drugs used for the treatment of anemia&#46;</p><p class="elsevierStylePara">In conclusion&#44; from the group of patients analyzed&#44; despite the high prevalence of those receiving ESAs and IV irons&#44; a significant fraction of them had Hb levels out of the range recommended by the RPCA-ERC&#47;SLANH&#46; Possible contributing factors and solutions to improve this problem require further investigation&#46; Therefore&#44; we are now beginning to re-collect data for the updated survey continuation that will allow us to increase the number of participating units and as a consequence&#44; the number of the HD patients&#46; Additionally&#44; this updated and expanded survey will make a significant contribution in strengthening the commitment and understanding of the management of anemia in HD patients in LA&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgements</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">ARGENTINA&#58;&#160;</span>Administradora de Salud SRL&#58; Dr&#46; Hugo Ram&#237;rez&#59; CENCOS &#40;Centro Nefrol&#243;gico Coronel Su&#225;rez&#41;&#58; Dr&#46; Carlos Alberto Alberdi&#59; CENDICA CADRA&#58; Dr&#46; Gordo Domingo Ponce&#44; Dr&#46; Arturo Guillermo Arias&#59; Centro del Ri&#241;&#243;n SRL&#58; Dr&#46; Norberto G&#243;mez&#59; Centro Hemodi&#225;lisis GA&#58; Dra&#46; Norma Gladys Nieto&#59; Centro Nefrol&#243;gico &#40;Centro de Di&#225;lisis&#41; Balcarce&#58; Dra&#46; Stella Trevis&#225;n&#44; Dr&#46; Denis Allende&#59; Centro Nefrol&#243;gico Integral&#58; Dr&#46; Ricardo Felix Tosello&#59; Centro Privado de Di&#225;lisis Tandil SA&#58; Dr&#46; Vito Mezzina&#59; CEPER San Francisco SH&#58; Dra&#46; Mar&#237;a Luisa Favaro&#59; CEPER Unidad Renal Arroyito&#58; Dra&#46; Alicia Lonatti&#59; CEPER Unidad Renal las Varillas&#58; Dr&#46; Jorge Rubiolo&#59; Cl&#237;nica Privada V&#233;lez Sarsfield&#58; Dr&#46; Rafael Alberto Maldonado&#59; Di&#225;lisis Madariaga&#58; Dr&#46; Estaban Lucas Siga&#59; Hospital Aeron&#225;utico Central&#58; Dr&#46; Carlos Blanco&#59; Hospital Brit&#225;nico de Buenos Aires&#58; Dra&#46;&#160;Vanesa Sabrina Pomeranz&#44; Dr&#46; Mariano Forresteri&#44; Dr&#46; Fernando Juan Lombi&#44; Dra&#46; Romina Paola Iriarte&#44; Dr&#46; Vicente Martin Campolo Girard&#44; Dr&#46; Hern&#225;n Trimarchi&#59; Hospital Churruca Visca&#58; Dra&#46;&#160;Liliana Andrade&#59; Instituto de Nefrolog&#237;a Pergamino &#40;Sucursal Rojas&#41; &#40;N1&#41;&#58; Dra&#46; Ana Mar&#237;a Cusumano&#59; Instituto de Nefrolog&#237;a y Hemodi&#225;lisis SRL&#58; Dr&#46; Miguel A&#46; Disc&#233;polo&#59; Instituto Pergamino SRL &#40;N2&#41;&#58; Dra&#46; Ana Mar&#237;a Cusumano&#59; Nefrolog&#237;a HAEDO SRL&#58; Dra&#46; Alicia Carlevaro&#59; Salud Renal SRL San Luis&#58; Dra&#46; Paula Gabriela Arenas&#59; Se Ne Ml Srl&#58; Dr&#46; Carlos D&#46; Braccalenti&#59; Servicios de Nefrolog&#237;a Cl&#237;nica Privada Mayo&#58; Dr&#46; Luis Eduardo Rivera&#59; Servicio de Nefrolog&#237;a y Hemodi&#225;lisis ANJOR SRL&#58; Dra&#46; Norma Nieto&#59; SOLANEF SRL &#40;San Francisco Solano Buenos Aires&#41;&#58; Dr&#46; Carlos Cangado Pousa&#59; Unidad 2115&#58; Dr&#46; Sergio Panese&#59; Unidad Cl&#237;nica Avenida&#58; Dr&#46; Daniel E&#46; Arrudi&#59; Unidad FAERAC&#58; Dr&#46; Eduardo Meneguzzi&#59; Unidad Renal Hospital Italiano&#58; Dra&#46; Marcela Alejandra Fern&#225;ndez&#59; Unidad Renal Rio Cuarto&#58; Dra&#46; Cecilia Grahovac&#46;&#160;<span class="elsevierStyleBold">BOLIVIA&#58;</span> Hospital Obrero N 1 &#40;La Paz&#41;&#58; Dr&#46; Roberto Barriga Arroyo&#46;<span class="elsevierStyleBold">&#160;BRASIL&#58;</span> Associa&#231;&#227;o Renal Vida Blumenau&#58; Dr&#46; Humberto Rebello Narciso&#59; Centro de Nefrolog&#237;a do Maranh&#227;o CENEFRON&#58; Dr&#46; Natalino Salgado&#59; Centro de Terapia Renal de Itabora&#237; &#40;CTRI&#41;&#58; Dra&#46; Elisa Albuquerque&#59; Centro de Tratamento Renal&#58; Dra&#46; Luc&#237;la Mar&#237;a Valente&#59; Cl&#237;nica de Medicina Interna e Nefrolog&#237;a&#58; Dra&#46; Patr&#237;cia Ferreira Abreu&#59; Cl&#237;nica de Nefrolog&#237;a de Sergipe CLINESE&#58; Dr&#46; Kleyton de Andrade Bastos&#59; Cl&#237;nica de Tratamento Nefrol&#243;gico&#58; Dra&#46; Silvana Mour&#227;o&#59; CLIRE Cl&#237;nica de Doen&#231;as Renais Ltda&#58; Dra&#46; Rosely Riki Matsubara&#59; Dialise do Hospital das Cl&#237;nicas da Faculdade de Medicina de Botucatu&#58; Dra&#46;&#160;Jacqueline Teixeira&#160; Caramori&#59; Funda&#231;&#227;o Oswaldo Ramos&#58; Dra&#46; Maria Eug&#234;nia Fernandes Canziani&#59; GAMEN&#58; Dra&#46;&#160;Maria da Gloria Mesquita Santiago Lima&#59; Hospital Universitario Presidente Dutra HUPD&#58; Dr&#46; Natalino Salgado&#59; Instituto de Doen&#231;as Renais LTDA &#40;Rio Grande do Sul&#41;&#58; Dr&#46; Fernando Saldanha Thom&#233;&#44; Dr&#46; Elvino Barros&#59; Instituto de Hemodi&#225;lise Sorocaba&#58; Dr&#46; Jos&#233; Lu&#237;s Bevilacqua&#59; Instituto do Rim do Paran&#225;&#58; Dr&#46; S&#233;rgio Gardano El&#237;as Bucharles&#59; Renaclin Clinica de Doen&#231;as Renais&#58; Dra&#46; M&#225;rcia Bastos&#59; Unicom - Sociedade de Nefrolog&#237;a Ltda&#58; Dr&#46; Fernando Frattini Neto&#59; Unidade de Tratamento Dial&#237;tico&#58; Dr&#46; Waldir Eduardo Garcia&#46;&#160;<span class="elsevierStyleBold">CHILE&#58;</span> Centro de Di&#225;lisis Cl&#237;nica Antofagasta&#58; Dr&#46; Eric Z&#250;&#241;iga Saravia&#59; Centro de Di&#225;lisis Hospital Cl&#237;nico Fusat&#58; Dra&#46; Anna Mar&#237;a Ar&#233;valo Ar&#233;valo&#59; Centro de Di&#225;lisis Tome Ltda Sucursal Penco&#58; Dr&#46; Jos&#233; Luis L&#243;pez&#44; Dra&#46; Claudia Cerna&#59; Centro de Di&#225;lisis Vallenar Ltda&#58; Dr&#46; Enrique Quintana Meneses&#59; Centro Hemodi&#225;lisis MEDICEN&#58; Dra&#46; Mar&#237;a Eugenia Est&#233;vez Molina&#59; Centro M&#233;dico y Di&#225;lisis TilTil Ltda&#58; Dra&#46; Ana Sota&#59; Centro Nefrol&#243;gico de Di&#225;lisis TOME Ltda&#58; Dra&#46; Mar&#237;a Jos&#233; Aliaga&#44; Dr&#46; Jorge Morente Esquivel&#59; Centro Regional de Di&#225;lisis Araucarias Thno Sucursal Hualpen&#58; Dr&#46; Jaime Lastra Salcedo&#59; Centro Regional de Di&#225;lisis Ltda &#40;Concepci&#243;n&#41;&#58; Dr&#46; Jaime Lastra Salcedo&#59; Centro Salud Anteres SA&#58; Dr&#46; Hern&#225;n E&#46; Echeverr&#237;a Torres&#59; Cl&#237;nica Alemana de Santiago SA&#58; Dr&#46; Enrique Reynolds H&#46;&#59; Cl&#237;nica D&#225;vila&#58; Dr&#46; Claudio Gonz&#225;lez Torres&#59; Cl&#237;nica Las Condes&#58; Dr&#46; Rodrigo Orozco&#59; Corporaci&#243;n Paul Harris&#58; Dr&#46; Antonio Saffie Ib&#225;&#241;ez&#59; Di&#225;lisis &#209;u&#241;oa&#58; Dr&#46; Luis Eduardo Ortiz Brieva&#59; Di&#225;lisis Calama Ltda&#58; Dr&#46; Fernando Gonz&#225;lez&#59; Di&#225;lisis Cl&#237;nica Indisa&#58; Dr&#46; Andr&#233;s Boltansky&#59; Di&#225;lisis Hospital Regional Rancagua&#58; Dr&#46; Juan Romero Tomasevich&#59; Di&#225;lisis Los Andes Ltda&#58; Dr&#46; Juan Lemus&#59; Di&#225;lisis Recoleta&#58; Dra&#46; Mar&#237;a Eugenia Sanhueza&#59; Hospital Carlos Van Buren&#58; Dr&#46; Hugo Poblete Badal&#59; Hospital Dr Hern&#225;n Henr&#237;quez Aravena&#58; Dr&#46; Arturo Pinto Zabaleta&#59; Hospital Exequiel Gonz&#225;lez Cort&#233;s&#58; Dr&#46; Jean Grandy Henr&#237;quez&#59; Hospital Luis Calvo Mackenna&#58; Dra&#46; Ana Mar&#237;a Lillo&#59; Hospital Puerto Natales&#58; Dra&#46; Paulina Folch&#59; Hospital de Coquimbo&#58; Dra&#46; Doris Subiabre Cortes&#59; Hospital Naval Almirante Nef&#58; Dr&#46; Gonzalo Silva Rojas&#59; Rancagua Dial Ltda&#58; Dr&#46; H&#233;ctor Labbe Saffa&#59; Saludial Concepci&#243;n y Saludial Coronel&#58; Dr&#46; Jorge M&#252;nzenmayer B&#59; Sermidial Valparaiso&#58; Dra&#46; Esperanza Merch&#225;n Molina&#59; Sermidial Vi&#241;a del Mar&#58; Dra&#46; Mar&#237;a Carlina Vargas Serrano&#59; Unidad de Di&#225;lisis Hospital Ancud&#58; Dra&#46; Katia Vel&#225;squez Mart&#237;nez&#59; Unidad de Hemodi&#225;lisis Hospital Regional Copiap&#243;&#58; Dr&#46; Guillermo Callejas Gonz&#225;lez&#59; Vitta Dial Los Andes&#58; Dr&#46; Pablo Merch&#225;n C&#243;rdova&#46;&#160;<span class="elsevierStyleBold">COLOMBIA&#58;&#160;</span>Biorrenal&#58; Dr&#46; Jaime Jos&#233; Torres Saltar&#237;n&#46;&#160;<span class="elsevierStyleBold">ECUADOR&#58; </span>Cl&#237;nica de los Ri&#241;ones MENYDIAL&#58; Dr&#46; Dar&#237;o Jim&#233;nez Acosta&#59; Instituto Ecuatoriano de Di&#225;lisis y Trasplante IEDYT&#58; Dr&#46; Fabi&#225;n Ortiz&#58; Herbener&#46; <span class="elsevierStyleBold">HONDURAS&#58;</span> Unidad de Hemodi&#225;lisis IHSS &#40;Tegucigalpa&#41;&#58; Dr&#46; Gaspar Rodr&#237;guez M&#46;<span class="elsevierStyleBold">&#160;M&#201;XICO&#58;</span> Centro Hospitalario la Concepci&#243;n de Saltillo&#58; Dr&#46; Mario Gast&#243;n Melo&#44; Dra&#46; Mar&#237;a Dolores del Bosque Saucedo&#59; Hemodi&#225;lisis Hospital San Jos&#233; Tec de Monterrey&#58; Dr&#46; Alejandro Vald&#233;s Cepeda&#59; Hospital Central Dr&#46; Ignacio Morones Prieto&#58; Dr&#46; Francisco Gerardo Alfaro Abundiz&#44; Dr&#46; Jes&#250;s Mart&#237;nez Reyna&#59; Hospital General Zona &#35; 2&#58; Dr&#46; Alfonso Ramos S&#225;nchez&#59; Hospital Regional de Zona IMSS&#58; Dra&#46; Patricia Mu&#241;oz Sotelo&#59; Hospital Star Medica Morelia&#58; Dr&#46; Eduardo Quintana Pi&#241;a&#59; Hospital Universitario Jos&#233; Eleuterio Gonz&#225;lez&#58; Dr&#46; Edgar Marcelo Arellano Torres&#59; Instituto Mexicano del Seguro Social &#40;IMSS&#41; HGZ N 8&#58; Dr&#46; Javier Pi&#241;&#243;n Escobedo&#59; Instituto de Seguridad y Servicios Sociales de los Trabajadores ISSSTE&#58; Dr&#46; Javier Pi&#241;&#243;n Escobedo&#59; Subsecci&#243;n de Hemodi&#225;lisis Hospital Central Militar&#58; Dr&#46; Ricardo Mendiola Fern&#225;ndez&#44; Dr&#46; Gustavo A&#46; Mart&#237;nez&#59; Unidad de Hemodi&#225;lisis Hospital General Regional No&#46; 25 del IMSS&#58; Dr&#46; Antonio M&#233;ndez Dur&#225;n&#59; Unidad Renal Ambulatoria&#58; Dr&#46; Javier Pi&#241;&#243;n Escobedo&#46;<span class="elsevierStyleBold">&#160;NICARAGUA&#58;&#160;</span>Hospital Salud Integral&#58; Dra&#46; Nubia Cano&#46; <span class="elsevierStyleBold">PANAM&#193;&#58;</span>&#160;Unidad Hospital Susana Jones Cano&#58; Dra&#46; Mar&#237;a Niedda&#46; <span class="elsevierStyleBold">PARAGUAY&#58;</span> Departamento de Nefrolog&#237;a Hospital de Cl&#237;nicas FMC-UNA&#58; Dra&#46; Elvira Gim&#233;nez Rol&#243;n&#59; Hospital Regional Encarnaci&#243;n&#58; Dr&#46; Dar&#237;o Cuevas&#59; Hospital Nacional&#58; Dra&#46; Mar&#237;a Concepci&#243;n R&#237;os&#44; Dra&#46; Miriam L&#243;pez&#59; Servicio de Nefrolog&#237;a Hospital Central de IPSS&#58; Dr&#46; Roger Aureliano Ayala Ferrari&#46;&#160;<span class="elsevierStyleBold">PER&#218;&#58;&#160;</span>Centro Nefrol&#243;gico SA Cenesa&#58; Dr&#46; Le&#243;nidas Carrillo&#59; Hospital Centro M&#233;dico Naval&#58; Dr&#46; Ernesto Valencia Valz&#59; San Fernando SAC&#58; Dr&#46; Pedro Castillo Rodr&#237;guez&#46; <span class="elsevierStyleBold">PUERTO RICO&#58; </span>Hospital Renal Universitario&#58; Dr&#46; Pedro Carlos Pagan Torres&#46;<span class="elsevierStyleBold">&#160;REP&#218;BLICA DOMINICANA&#58;</span> Hospital Regional Dr&#46; Antonio Musa Unidad de Di&#225;lisis&#58; Dra&#46; Sandra Rodr&#237;guez Manzano&#46;&#160;<span class="elsevierStyleBold">URUGUAY&#58;</span> Uruguayana&#58; Dra&#46; Nieves Campistr&#250;s&#59; Asociaci&#243;n M&#233;dica de San Jos&#233;&#58; Dr&#46; Alejandro Ferreiro&#59; Centro de Di&#225;lisis Cr&#243;nica Hospital Maciel&#58; Dra&#46;&#160;Laura Sol&#225;&#59; Centro Nefrol&#243;gico Integral Camedur&#58; Dra&#46; Virginia Matonte&#59; COMERO &#40;Rocha&#41;&#58; Dra&#46; Cecilia Tognola&#59; COMEPA&#58; Dra&#46; Mariela Odriozola&#44; Dra&#46; Marta Pereyra&#44; Dra&#46;&#160;Marcela Daglio&#59; Di&#225;lisis del Hospital Brit&#225;nico&#58; Dr&#46; Juan Fern&#225;ndez Cean&#44; Dra&#46; Catalina Guti&#233;rrez&#59; INU&#58; Dra&#46; Enriqueta Carbonell&#59; SARI- IBIRAPITA&#58; Dra&#46; Alicia Petraglia&#44; Dra&#46; Anal&#237;a Varela&#59; SE&#46;NE&#46;C&#46;C&#46; &#40;Centro de Di&#225;lisis de COMECA&#41;&#58; Dra&#46; Lydia Zampedri&#59; Unidad CEDINA&#58; Dr&#46; Juan Carlos D&#237;az&#44; Dra&#46; Aquelina &#193;lvarez&#46;&#160;<span class="elsevierStyleBold">VENEZUELA&#58;</span> Unidad Hospital N&#250;&#241;ez Tovar&#58; Dr&#46; Carlos M&#225;rquez&#44; Dr&#46; Andr&#233;s Cortez&#59; Hospital Universitario de Los Andes M&#233;rida&#58; Dr&#46; Bernardo Fargier&#44; Dra&#46; Dulce Winterdaal&#59; Di&#225;lisis San Antonio CA&#58; Dr&#46; Silvano Vernamonte Damiani&#59; Unidad de Di&#225;lisis GAPB Guatire&#58; Dr&#46; Leoncio Serrano&#59; Unidad de Di&#225;lisis Hospital Militar Caracas&#58; Dr&#46; Leoncio Serrano Centro M&#233;dico Docente La Trinidad&#58; Dra&#46; Ana Mar&#237;a San&#225;nez&#59; Centro Nefrol&#243;gico Integral Falc&#243;n&#58; Dr&#46; Ram&#243;n Polanco&#59; Hospital de Cl&#237;nicas Caracas&#58; Dra&#46; Julia Bravo&#44; Dra&#46; Leonor Oliveros&#44; Dr&#46; Pablo Amair&#59; Servicios Nefrol&#243;gicos CA&#58; Dra&#46; Belquis Chuecos&#59; Unidad de Hemodi&#225;lisis Naguanagua&#58; Dr&#46; David L&#243;pez&#44; Dr&#46; Orleans M&#233;ndez&#59; Unidad de Hemodi&#225;lisis Jes&#250;s de Nazareno CA N 1&#58; Dra&#46; Silvia Villarroel&#59; Unidad de Hemodi&#225;lisis Jes&#250;s de Nazareno CA N 2&#58; Dra&#46; Silvia Villarroel&#59; Unidad Di&#225;lisis M&#233;rida &#40;DIAMERCA&#41;&#58; Dr&#46; Bernardo Fargier&#44; Dr&#46; Luis Guilarte&#46;&#160;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interest</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">The authors declare that there is no conflict of interest associated with this manuscript&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12234&#95;19904&#95;49638&#95;en&#95;12234&#95;16025&#95;49638&#95;en&#95;t112234&#46;jpg" class="elsevierStyleCrossRefs"><img src="12234_19904_49638_en_12234_16025_49638_en_t112234.jpg" alt="Baseline demographic and clinical characteristics of 9&#44;025 Latin American hemodialysis patients&#46;"></img></a></p><p class="elsevierStylePara">Table 1&#46; Baseline demographic and clinical characteristics of 9&#44;025 Latin American hemodialysis patients&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12234&#95;19904&#95;49642&#95;en&#95;12234&#95;16025&#95;49642&#95;en&#95;t212234&#46;jpg" class="elsevierStyleCrossRefs"><img src="12234_19904_49642_en_12234_16025_49642_en_t212234.jpg" alt="Anemia treatment in 9&#44;025 Latin American hemodialysis patients&#46;"></img></a></p><p class="elsevierStylePara">Table 2&#46; Anemia treatment in 9&#44;025 Latin American hemodialysis patients&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12234&#95;19904&#95;49643&#95;en&#95;12234&#95;16025&#95;49643&#95;en&#95;f112234&#46;jpg" class="elsevierStyleCrossRefs"><img src="12234_19904_49643_en_12234_16025_49643_en_f112234.jpg" alt="Distribution of the hemoglobin levels by the participating countries&#46;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Distribution of the hemoglobin levels by the participating countries&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12234&#95;19904&#95;49645&#95;en&#95;12234&#95;16025&#95;49645&#95;en&#95;t312234&#46;jpg" class="elsevierStyleCrossRefs"><img src="12234_19904_49645_en_12234_16025_49645_en_t312234.jpg" alt="Associations between anemia management variables and hemoglobin levels&#46;"></img></a></p><p class="elsevierStylePara">Table 3&#46; Associations between anemia management variables and hemoglobin levels&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Antecedentes&#58; </span>La anemia representa una complicaci&#243;n frecuente en pacientes con enfermedad renal cr&#243;nica&#46; En Latinoam&#233;rica &#40;LA&#41; la prevalencia y caracter&#237;sticas de la anemia en pacientes en hemodi&#225;lisis &#40;HD&#41; no ha sido bien estudiada&#46; <span class="elsevierStyleBold">Objetivo&#58; </span>Evaluar los resultados del primer registro de anemia del Comit&#233; de Anemia de la Sociedad Latinoamericana de Nefrolog&#237;a e Hipertensi&#243;n&#46; <span class="elsevierStyleBold">M&#233;todos&#58; </span>Esta es una encuesta multinacional&#44; voluntaria&#44; que recolect&#243; datos sobre el tratamiento de la anemia en pacientes en HD de unidades independientes en LA entre septiembre de 2009 y marzo de 2010&#46; Para el an&#225;lisis estad&#237;stico se utilizaron los siguientes m&#233;todos&#58; t-test&#44; ANOVA&#44; chi<span class="elsevierStyleSup">2</span> y el an&#225;lisis de regresi&#243;n log&#237;stica multivariante&#46; <span class="elsevierStyleBold">Resultados&#58;</span> La encuesta fue respondida por 134 unidades de HD de 16 pa&#237;ses&#44; recibi&#233;ndose datos de 9025 pacientes&#46; Las medias &#177; desviaci&#243;n est&#225;ndar de Hb&#44; ferritina y del &#237;ndice de saturaci&#243;n de transferrina &#40;IST&#41; fueron respectivamente&#58; 10&#44;5 &#177; 1&#44;8 g&#47;dl&#44; 570 &#177; 539 &#181;g&#47;l y 29&#44;8&#160;&#37; &#177; 15&#46; Se administr&#243; agentes estimulantes de la eritropoyesis &#40;AEE&#41; al 84&#44;3&#160;&#37; de los pacientes y hierro intravenoso &#40;FeIV&#41; al 68&#44;3&#160;&#37;&#46; Solamente el 32&#44;7&#160;&#37; de los pacientes tuvieron una Hb blanco de 10&#44;5-12&#44;0 g&#47;dl&#46; En pacientes con Hb &#60;&#160;10&#44;5 g&#47;dl&#44; el 85&#44;2&#160;&#37; estaban recibiendo AEE y un 68&#160;&#37; FeIV&#46; Las variables independientes asociadas con nivel Hb &#60;&#160;10&#44;5 g&#47;dl fueron&#58; g&#233;nero femenino&#44; IST&#160;&#60;&#160;25&#160;&#37; y edad &#60;&#160;50 a&#241;os&#46;&#160; En la muestra de pacientes analizada&#44; a pesar del amplio uso de los AEE y FeIV&#44; casi la mitad de los pacientes no alcanz&#243; la Hb blanco&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Background&#58; </span>Anemia almost invariably occurs in patients with chronic kidney disease&#46; Limited data are available regarding anemia management in Latin American &#40;LA&#41; hemodialysis &#40;HD&#41; patients&#46; <span class="elsevierStyleBold">Objective</span>&#58; To evaluate the results of the first anemia survey of the Anemia Committee of the SLANH&#46; <span class="elsevierStyleBold">Methods&#58;</span> This is a multinational&#44; voluntary survey that collected anemia management data from adult HD patients from independent&#44; non-chain owned HD units&#44; between 09&#47;2009 and 03&#47;2010&#46; T-test&#44; ANOVA&#44; chi-square test and multivariate logistic regression were used for statistical analysis&#46; <span class="elsevierStyleBold">Results&#58; </span>The survey received responses from 134 HD units of 16 countries providing data from 9&#44;025 patients&#46; Mean values of Hb&#44; ferritin&#44; and transferrin saturation &#40;TSAT&#41; were 10&#46;5&#177;1&#46;8g&#47;dL&#44; 570&#177;539&#181;g&#47;l&#44; and 29&#46;8&#177;15&#37;&#44; respectively&#46; Only 32&#46;7&#37; of patients were within the Hb target of 10&#46;5-12&#46;0g&#47;dL &#40;46&#46;3&#37; were below and 21&#46;1&#37; above&#41;&#46; Erythropoietin-stimulating agents &#40;ESAs&#41; were administered to 84&#46;3&#37; patients and 68&#46;3&#37; received intravenous iron &#40;IV&#41;&#46; Iron deficiency &#40;TSAT&#8804;20&#37;&#41; was present in 27&#46;5&#37; patients and among those receiving erythropoietin&#44; 47&#37; did not achieve Hb target&#46; The independent variables associated with the lowest Hb level &#40;&#60;10&#46;5g&#47;dL&#41; were&#58; female gender&#44; TSAT¿25&#37; and age&#60;50 years&#46; <span class="elsevierStyleBold">Conclusions&#58; </span>According to these results&#44; nearly half of LA chronic HD patients did not achieve the recommended Hb target despite wide use of ESAs and IV iron&#46;</p>"
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The First Report of The Latin American Society of Nephrology and Hypertension (SLANH) Anemia Committee in Chronic Hemodialysis Patients
Primer Informe del Comité de Anemia en Pacientes en Hemodiálisis Crónica de la Sociedad Latinoamericana de Nefrología e Hipertensión (SLANH)
Raúl Carlinia, Raul Carlinia, Gregorio Obradorb, Nieves Campistrúsc, Liliana Andraded, Liliana Chifflete, Rachel Bregmanf, Alberto Locatellig, Ricardo Correa-Rotterh, Hugo Pobletei
a Division of Nephrology, University Hospital of Caracas, Caracas, Venezuela,
b School of Medicine, Panamerican University, Ciudad City, México,
c Dialysis Center Uruguayana, Montevideo, Uruguay,
d Hospital Policial Medical Complex Churruca-Visca, Buenos Aires, Argentina,
e Division of Dialysis, San José Medical Association, San José de Mayo, Uruguay,
f Rio de Janeiro State University, Rio de Janeiro, Brazil,
g Nefronosa Service SA, Buenos Aires,
h Department of Nephrology and Mineral Metabolism, Institute of Nutrition, Salvador Zubirán, Mexico City, Mexico,
i Dialysis Center Sermedial, Valparaíso, Chile,
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reported that normalization of Hb was associated with no benefit in terms of cardiovascular morbidity and mortality&#44; and with an increased risk of stroke and cancer in patients with a history or current malignancy&#46;<span class="elsevierStyleSup">1-3</span> A recent study by Coyne demonstrated that in HD patients with ischemic heart disease or heart failure&#44; higher Hb &#40;13-15g&#47;dL&#41; could increase nonfatal myocardial infarcts&#44; deaths&#44; and has no effect in improving quality of life compared to those with Hb of 11g&#47;dL&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">Since 1997&#44; several clinical practice guidelines for the management of anemia of CKD have been published&#46; The 2007 version of the National Kidney Foundation-Kidney Disease Quality Outcomes Initiative &#40;NKF-KDOQI&#41; suggested a Hb target between 11 and 12g&#47;dL&#44; while avoiding levels above 13g&#47;dL&#46;<span class="elsevierStyleSup">5</span> Two years later&#44; the Anemia Working Group of European Renal Best Practice &#40;ERBP&#41; endorsed these recommendations&#46;<span class="elsevierStyleSup">6</span> In 2008&#44; the Anemia Working Group of the Latin American Society of Nephrology and Hypertension &#40;SLANH&#41; &#40;RPCA-ERC&#47;SLANH&#41; recommended to maintain Hb levels between 10&#46;5 and 12g&#47;dL&#44; ferritin levels between 200 and 500&#956;g&#47;L and transferrin saturation &#40;TSAT&#41; levels between 30 and 40&#37;&#46;<span class="elsevierStyleSup">7</span> Finally&#44; the recently published Kidney Disease Improving Global Outcomes &#40;KDIGO&#41; anemia guidelines suggested to consider starting ESAs therapy in iron replete HD patients when the Hb levels are between 9&#46;0 and 10&#46;0g&#47;dL&#44; and to maintain it at &#8804;11&#46;5g&#47;dL&#46; It also recommended to individualize therapy by taking into consideration the balance between benefits of reducing blood transfusions and anemia-related symptoms and risks associated with ESAs therapy&#46;<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara">In the Latin American &#40;LA&#41; region&#44; little is known about anemia management in dialysis patients&#46; Interestingly&#44; LA patient populations consist of a variety of races that live anywhere from sea level to mountainous regions with altitudes as high as 13&#44;000 feet&#46; Furthermore&#44; there are important socioeconomic disparities and health care systems that vary from country to country&#46; These and other factors may influence anemia management in CKD patients resulting in variations in Hb levels&#46;</p><p class="elsevierStylePara">The Latin American Society of Nephrology and Hypertension &#40;SLANH&#41; survey collected data of patients receiving kidney replacement therapy in 20 LA countries&#46; In its latest report&#44; 147&#44;158 patients were receiving chronic HD in the region&#46;<span class="elsevierStyleSup">9</span> However&#44; scant anemia management data are available&#46; Therefore&#44; under the auspices of the SLANH&#44; the Latin American Anemia Committee was established to specifically address this issue&#46;</p><p class="elsevierStylePara">In this paper&#44; we present the first report of the SLANH&#8217;s anemia survey with data on 9&#44;025 HD patients from 16 LA countries&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">METHODS</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">In this cross-sectional study&#44; a survey developed by the Anemia Committee was sent to SLANH&#8217;s affiliated national societies of nephrology and was then distributed to the different local dialysis units who were independent&#44; non-chain owned&#46; Nephrologists were requested to fill out the survey with anemia management data collected between September and December 2009&#44; although this period had to be extended through March 2010&#46;</p><p class="elsevierStylePara">Inclusion criteria were adult &#40;&#8805;18 years of age&#41; patients receiving chronic HD for at least 3 months&#46; Data collected included age&#44; gender&#44; cause of CKD&#44; dry weight&#44; last Kt&#47;V&#44; time on HD&#44; type of ESA used&#44; total weekly dose&#44; route of administration &#91;intravenous &#40;IV&#41; or subcutaneous &#40;SC&#41;&#93;&#44; type of IV iron preparation used&#44; total monthly dose&#44; last Hb&#44; ferritin&#44; and TSAT &#40;during the data collection period&#41;&#44; and blood transfusion use during the prior two months&#46;</p><p class="elsevierStylePara">Databases of each country were validated and merged into a single database&#46; Missing and out-of-range values were excluded&#46; Acceptable ranges were as follows&#58; Hb&#58; 3-16g&#47;dL&#44; ferritin&#58; &#60;5&#44;000&#181;g&#47;L&#44; TSAT&#58; 5-100&#37;&#44; time on HD&#58; 0&#46;3-28 years&#44; Kt&#47;V&#58; 0&#46;5-3&#46;5&#44; weekly ESA dose &#40;erythropoietin-&#945; or &#946;&#41;&#58; 1&#44;000-30&#44;000IU&#44; and monthly IV iron dose&#58; 50-2&#44;400mg&#46; Selection of these ranges was based on the distribution of data and clinical judgment&#46; Descriptive statistics were used to analyze patient and anemia management data&#46; T-test or ANOVA were used for continuous variables and chi square test for categorical variables&#46; A p-value of &#60;0&#46;05 was considered statistically significant&#46; For some analyses&#44; patients were stratified according to Hb level &#60;10&#46;5g&#47;dL &#40;low&#41;&#44; 10&#46;5-12&#46;0g&#47;dL &#40;target range&#41;&#44; and &#62;12&#46;0g&#47;dL &#40;high&#41;&#46; Multivariate conditional logistic regression analysis was performed to determine factors associated with Hb&#8805;10&#46;5g&#47;dL versus &#8804;10&#46;5g&#47;dL&#46;</p><p class="elsevierStylePara">Independent variables were entered by the stepwise forward method and included age&#44; gender&#44; ferritin&#44; TSAT and Kt&#47;V levels&#46; All statistical analyses were performed with the Statistical Package for Social Sciences SPSS&#44; version 17&#44; Chicago&#44; IL&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Baseline patient characteristics</span></p><p class="elsevierStylePara">A total of 171 surveys from the same number of unit hemodialysis centers were received&#46; From those surveys&#44; 134 had all inclusion criteria and a total of 9&#44;025 chronic HD patients from 16 LA countries were incorporated in the analysis&#46; Baseline patient characteristics are shown in Table 1&#46; Mean age of the patients was 57&#46;4&#177;15&#46;7 years and 58&#37; were men&#46; Causes of CKD were arterial hypertension &#40;40&#46;8&#37;&#41;&#44; diabetes mellitus &#40;29&#46;7&#37;&#41;&#44; glomerular disease &#40;18&#46;1&#37;&#41; and other causes &#40;11&#37;&#41;&#46; Mean time in HD was 3&#46;9&#177;3&#46;8 years&#46; Brazil&#44; Chile&#44; and Argentina accounted for two-thirds of the patients &#40;34&#46;1&#37;&#44; 17&#46;5&#37;&#44; and 15&#46;2&#37;&#44; respectively&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Anemia management</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">Results of anemia management are shown in Table 2&#46; The majority of patients &#40;84&#46;7&#37;&#41; were receiving some type of ESA during the study period&#46; Erythropoietin-&#945; and erythropoietin-&#946; were used in 73&#37; and 10&#46;1&#37; of the patients&#46; The median weekly dose for erythropoietin-&#945; was 6&#44;000IU with SC administration and 11&#44;000IU with IV administration and the corresponding average SC weekly doses were 7&#44;330&#177;4&#44;276UI&#47;week or &#40;118&#177;75UI&#47;Kg&#47;week&#41; and 10&#44;622&#177;6&#44;072UI&#47;week &#40;171&#177;104UI&#47;Kg&#47;week&#41;&#44; respectively &#40;p&#61;0&#46;0001&#41;&#46; ESAs were more often administered by the SC route &#40;83&#46;9&#37;&#41;&#46;</p><p class="elsevierStylePara">About two thirds &#40;68&#46;3&#37;&#41; of the patients were receiving IV iron&#46; Iron saccharate and low molecular weight iron dextran were used in 56&#46;3&#37; and 10&#37; of patients&#44; respectively&#46; The median iron monthly dose for both iron preparations was 200mg&#44; whereas the mean monthly doses for iron sacharate were 317&#177;243mg &#40;range 50-1&#44;400mg&#47;month&#41; and for the low molecular iron weight iron dextran 318&#177;230mg &#40;range 50-1&#44;000mg&#47;month&#41;&#46; No significant differences in mean iron doses were observed between male and females&#44; or between patients with or without diabetes&#46; Blood transfusions in the prior two months were given to 8&#46;2&#37; of patients&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Hemoglobin and iron values</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">Mean &#40;&#177;SD&#41; values of Hb &#40;n&#61;9&#44;025&#41;&#44; ferritin &#40;n&#61;7&#44;915&#41;&#44; and TSAT &#40;n&#61;5&#44;705&#41; were 10&#46;5&#177;1&#46;8g&#47;L&#44; 570&#177;539mg&#47;L&#44; and 29&#46;8&#177;15&#37;&#44; respectively&#46; Most of the women &#40;52&#37;&#41; had Hb&#8804;10&#46;5g&#47;dL&#44; meanwhile 58&#37; of the men had Hb&#8805;10&#46;5g&#47;dL &#40;p&#61;0&#46;0001&#41;&#46; However&#44; ESA doses were higher in women &#40;137U&#47;Kg&#47;week&#41; than in men &#40;116U&#47;Kg&#47;week&#41;&#44; &#40;p&#61;0&#46;0001&#41;&#46;</p><p class="elsevierStylePara">Only 32&#46;7&#37; of patients were within the Hb target recommended by the RPCA-ERC&#47;SLANH&#44; the remaining 46&#46;3&#37; and 21&#46;1&#37; of patients had Hb levels below &#40;&#60;10&#46;5g&#47;dL&#41; or above &#40;&#62;12&#46;0g&#47;dL&#41; the recommended target&#44; respectively&#46; Figure 1 shows the distribution of Hb levels by the participating countries&#46; Chile&#44; Paraguay and Venezuela were the countries with the lowest mean Hb values &#40;&#60;10&#46;5g&#47;dL&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Factors associated with hemoglobin levels</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">Table 3 depicts univariate associations between several anemia management variables and Hb levels within and outside the recommended target&#46; A higher TSAT was associated with <br></br>the highest Hb levels&#46; Additionally&#44; higher ESA and IV iron doses were associated with Hb levels below the recommended target&#46; Among patients with Hb level between 10&#46;5-12g&#47;dL&#44; 62&#46;4&#37; had TSAT&#8805;25&#37;&#44; whereas only 46&#46;6&#37; of those with Hb levels &#60;10&#46;5g&#47;dL had a TSAT&#8804;25&#37; &#40;p&#61;0&#46;0001&#41;&#46; Moreover&#44; in the group with Hb&#60;10&#46;5g&#47;dL&#44; the ESAs were prescribed in 84&#44;3&#37; and iron IV in 68&#46;3&#37; of the patients&#46; Further variables&#44; such as ferritin and Kt&#47;V&#44; were not significantly different among the Hb groups&#46; The results of a multivariate logistic regression analysis demonstrated that the variables independently associated with Hb levels &#60;10&#46;5g&#47;dL were&#58; age&#8804;50 years &#40;RR&#61;1&#46;17&#44; 95&#37;CI&#61;1&#46;04-1&#46;32&#44; p&#60;0&#46;01&#41;&#44; female &#40;RR&#61;1&#46;37&#44; 95&#37;CI&#61;1&#46;22-1&#46;54&#44; p&#60;0&#46;001&#41;&#44; and TSAT&#8804;25&#37; &#40;RR&#61;1&#46;43&#44; 95&#37;CI&#61;1&#46;27-1&#46;6&#44; p&#60;0&#46;0001&#41; &#40;data not shown&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">The main findings of this first report of the SLANH&#8217;s anemia survey can be summarized as follows&#58; a&#41; the majority of patients attending independent&#44; not-chain owned chronic HD facilities were receiving an ESA&#59; b&#41; erythropoietin &#945; was more frequently used&#44; at a median weekly dose of 6&#44;000IU SC and 11&#44;000IU IV&#59; c&#41; SC was the preferred route of ESA administration&#59; d&#41; two-thirds of patients were receiving IV iron&#59; e&#41; mean values of Hb&#44; ferritin&#44; and TSAT were 10&#46;5&#177;1&#46;8g&#47;dL&#44; 570&#177;539&#956;g&#47;L&#44; and 29&#46;8&#37;&#177;15&#37;&#44; respectively&#59; f&#41; only one-third of patients were within the SLANH&#8217;s recommended Hb target of 10&#46;5-12&#46;0g&#47;dL&#44; and nearly half of patients had Hb values below 10&#46;5g&#47;dL&#59; g&#41; age&#8804;50 years&#44; female&#44; and TSAT&#8804;25&#37; were independently associated with having a Hb level below the recommended target&#46;</p><p class="elsevierStylePara">Published anemia data in the management of chronic HD patients in LA is scarce&#46; Despite important limitations&#44; possible sources of information are individual Register from local LA nephrological societies&#46; The 2008 Brazilian Society of Nephrology&#8217;s Dialysis Census Report reported that 83&#37; of chronic HD patients were receiving an ESA and 53&#46;5&#37; an iron preparation&#46;<span class="elsevierStyleSup">10</span> Additionally&#44; 47&#46;7&#37; had Hb levels &#60;11g&#47;dL&#46; Another study of 32&#44;136 Brazilian chronic HD patients reported that being male and having an age of &#60;65 years&#44; diabetic CKD&#44; or an arteriovenous fistula&#44; were independently associated with ESAs use&#46;<span class="elsevierStyleSup">11</span></p><p class="elsevierStylePara">The 2009 Uruguayan Society of Nephrology Register reported that 94&#37; of chronic HD patients were receiving an ESA and 65&#37; iron&#59; it also reported that 62&#46;3&#37; of patients and 19&#46;5&#37; had Hb levels between 10&#46;5-12g&#47;dL and &#60;10g&#47;dL&#44; respectively&#46;<span class="elsevierStyleSup">12</span> The 2010 Register from the Chilean Society of Nephrology reported that&#44; among 14&#44;462 chronic HD patients&#44; 54&#46;6&#37; had a hematocrit &#60;30&#37;&#44; and that 42&#46;5&#37; were receiving ESA treatment and 51&#46;7&#37; IV iron&#46;<span class="elsevierStyleSup">13</span> Overall&#44; these data demonstrate that there is significant variability in anemia management among the different LA countries&#46;</p><p class="elsevierStylePara">Comparison of our results with those of other non-LA countries is difficult to assess in part due to variations of Hb target levels in chronic HD patients in different clinical practice guidelines&#46;<span class="elsevierStyleSup">8&#44;14&#44;15</span> This SLANH&#8217;s anemia survey is a first attempt to try to elucidate the status of anemia management among LA chronic HD patients&#46; We found that the median Hb level was 10&#46;5g&#47;dL and that only 34&#37; of patients had Hb levels within the target recommended by the RPCA-ERC&#47;SLANH&#46; However&#44; a subsequent statistical analysis showed that 61&#46;4&#37; of patients had Hb levels above 10g&#47;dL&#46; Surprisingly&#44; 84&#37; of the patients were receiving an ESA and 68&#37; IV iron treatment&#46;</p><p class="elsevierStylePara">Regarding ESA doses&#44; the mean SC dose of erythropoietin &#945; was 7&#44;330IU&#47;week and in the IV administration was 10&#44;662IU&#47;week to achieve median Hb levels of 10&#46;5g&#47;dL in slightly over one-third of patients&#46; Most other Society Registers do not report the discrimination between IV and SC ESAs doses&#46; The 2010 UK Annual Renal Register reported a mean ESA dose of 9&#44;507IU&#47;week and that 85&#37; of patients had Hb levels &#8805;10g&#47;dL&#44; with the median level being 11&#46;6g&#47;dL&#46;<span class="elsevierStyleSup">16</span> The 2012 US Renal Data Report shows that by the end of 2010&#44; the mean ESA dose was 15&#44;829IU&#47;week with an achieved mean Hb level of 11&#46;3g&#47;dL&#46; Roughly&#44; two-thirds of patients had Hb levels in the 10-12g&#47;dL range&#46; Additionally&#44; the highest doses of IV iron of 2&#44;700 mg or more were present in 24&#37; of patients who were treated jointly with ESAs&#46;<span class="elsevierStyleSup">17</span></p><p class="elsevierStylePara">In a recent report from Japan&#44; of 1&#44;622 patients the mean Hb was 10&#46;3g&#47;dL&#46; The majority were treated with ESAs &#40;82&#46;2&#37;&#41;&#44; but only 54&#37; of the patients had Hb levels within the target recommended by the Japanese guidelines&#46; The mean ESAs doses administered by IV were 4&#44;645IU&#47;week&#46;<span class="elsevierStyleSup">18</span></p><p class="elsevierStylePara">Our findings also demonstrate that the RPCA-ERC&#47;SLANH recommended levels of TSAT and ferritin &#40;&#62;25&#37; and &#8805;200&#956;g&#47;L&#44; respectively&#41; were associated with the highest Hb levels&#46; We also found a negative association between ferritin and TSAT with ESAs and iron IV doses&#46; The association between the low Hb and TSAT&#8804;25&#37; suggests that a functional iron deficiency could be present in a high percentage of patients&#46; However&#44; the low percentage of patients that were tested for TSAT &#40;63&#37;&#41; suggests that the assessment for a complete iron status testing is necessary for the adequate control of anemia in HD patients in LA&#46; The mechanism of poor anemia control detected in women&#44; even though receiving higher weight adjusted ESA doses&#44; was probably due to the fact that women were iron undertreated when compared to men &#40;47&#37; vs 52&#37;&#44; respectively&#41;&#46;</p><p class="elsevierStylePara">We also found that ESAs and iron IV doses were higher for patients with low Hb levels which could suggest ESA hyporesponsiveness&#46; Multivariable logistic regression analysis demonstrated that the independent variables associated with Hb level &#60;10&#46;5g&#47;dL were female gender&#44; TSAT&#8804;25&#37;&#44; and age&#8804;50 years&#46; Female gender and low TSAT are known as factors for ESA hyporesponsiveness&#46;<span class="elsevierStyleSup">19&#44;20</span> The variable age&#8804;50 year is probably because our HD population is younger than that reported in other populations&#46;</p><p class="elsevierStylePara">The inter-variation in the Hb levels between LA countries could be due to several causes&#44; such as anemia treatment &#40;including laboratory test and drugs&#41; which represents an important cost for the diverse health care systems&#46; This could reflect a potential restriction in anemia management practices&#44; not only for the prescription of inappropriate doses&#44; but also for the frequency of administration&#46;</p><p class="elsevierStylePara">Our study has several limitations&#46; It is cross-sectional with all the statistical limitations associated with this type of study design&#46; We only selected non-chain owned HD units&#44; primarily because there was an ease of access to obtain the data&#46; Since participation in the study was voluntary&#44; data from some countries were very limited&#44; and also some of the participating countries have data from only one HD unit&#46; The survey was not designed to evaluate the effectiveness of any of the drugs used for the treatment of anemia&#46;</p><p class="elsevierStylePara">In conclusion&#44; from the group of patients analyzed&#44; despite the high prevalence of those receiving ESAs and IV irons&#44; a significant fraction of them had Hb levels out of the range recommended by the RPCA-ERC&#47;SLANH&#46; Possible contributing factors and solutions to improve this problem require further investigation&#46; Therefore&#44; we are now beginning to re-collect data for the updated survey continuation that will allow us to increase the number of participating units and as a consequence&#44; the number of the HD patients&#46; Additionally&#44; this updated and expanded survey will make a significant contribution in strengthening the commitment and understanding of the management of anemia in HD patients in LA&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgements</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">ARGENTINA&#58;&#160;</span>Administradora de Salud SRL&#58; Dr&#46; Hugo Ram&#237;rez&#59; CENCOS &#40;Centro Nefrol&#243;gico Coronel Su&#225;rez&#41;&#58; Dr&#46; Carlos Alberto Alberdi&#59; CENDICA CADRA&#58; Dr&#46; Gordo Domingo Ponce&#44; Dr&#46; Arturo Guillermo Arias&#59; Centro del Ri&#241;&#243;n SRL&#58; Dr&#46; Norberto G&#243;mez&#59; Centro Hemodi&#225;lisis GA&#58; Dra&#46; Norma Gladys Nieto&#59; Centro Nefrol&#243;gico &#40;Centro de Di&#225;lisis&#41; Balcarce&#58; Dra&#46; Stella Trevis&#225;n&#44; Dr&#46; Denis Allende&#59; Centro Nefrol&#243;gico Integral&#58; Dr&#46; Ricardo Felix Tosello&#59; Centro Privado de Di&#225;lisis Tandil SA&#58; Dr&#46; Vito Mezzina&#59; CEPER San Francisco SH&#58; Dra&#46; Mar&#237;a Luisa Favaro&#59; CEPER Unidad Renal Arroyito&#58; Dra&#46; Alicia Lonatti&#59; CEPER Unidad Renal las Varillas&#58; Dr&#46; Jorge Rubiolo&#59; Cl&#237;nica Privada V&#233;lez Sarsfield&#58; Dr&#46; Rafael Alberto Maldonado&#59; Di&#225;lisis Madariaga&#58; Dr&#46; Estaban Lucas Siga&#59; Hospital Aeron&#225;utico Central&#58; Dr&#46; Carlos Blanco&#59; Hospital Brit&#225;nico de Buenos Aires&#58; Dra&#46;&#160;Vanesa Sabrina Pomeranz&#44; Dr&#46; Mariano Forresteri&#44; Dr&#46; Fernando Juan Lombi&#44; Dra&#46; Romina Paola Iriarte&#44; Dr&#46; Vicente Martin Campolo Girard&#44; Dr&#46; Hern&#225;n Trimarchi&#59; Hospital Churruca Visca&#58; Dra&#46;&#160;Liliana Andrade&#59; Instituto de Nefrolog&#237;a Pergamino &#40;Sucursal Rojas&#41; &#40;N1&#41;&#58; Dra&#46; Ana Mar&#237;a Cusumano&#59; Instituto de Nefrolog&#237;a y Hemodi&#225;lisis SRL&#58; Dr&#46; Miguel A&#46; Disc&#233;polo&#59; Instituto Pergamino SRL &#40;N2&#41;&#58; Dra&#46; Ana Mar&#237;a Cusumano&#59; Nefrolog&#237;a HAEDO SRL&#58; Dra&#46; Alicia Carlevaro&#59; Salud Renal SRL San Luis&#58; Dra&#46; Paula Gabriela Arenas&#59; Se Ne Ml Srl&#58; Dr&#46; Carlos D&#46; Braccalenti&#59; Servicios de Nefrolog&#237;a Cl&#237;nica Privada Mayo&#58; Dr&#46; Luis Eduardo Rivera&#59; Servicio de Nefrolog&#237;a y Hemodi&#225;lisis ANJOR SRL&#58; Dra&#46; Norma Nieto&#59; SOLANEF SRL &#40;San Francisco Solano Buenos Aires&#41;&#58; Dr&#46; Carlos Cangado Pousa&#59; Unidad 2115&#58; Dr&#46; Sergio Panese&#59; Unidad Cl&#237;nica Avenida&#58; Dr&#46; Daniel E&#46; Arrudi&#59; Unidad FAERAC&#58; Dr&#46; Eduardo Meneguzzi&#59; Unidad Renal Hospital Italiano&#58; Dra&#46; Marcela Alejandra Fern&#225;ndez&#59; Unidad Renal Rio Cuarto&#58; Dra&#46; Cecilia Grahovac&#46;&#160;<span class="elsevierStyleBold">BOLIVIA&#58;</span> Hospital Obrero N 1 &#40;La Paz&#41;&#58; Dr&#46; Roberto Barriga Arroyo&#46;<span class="elsevierStyleBold">&#160;BRASIL&#58;</span> Associa&#231;&#227;o Renal Vida Blumenau&#58; Dr&#46; Humberto Rebello Narciso&#59; Centro de Nefrolog&#237;a do Maranh&#227;o CENEFRON&#58; Dr&#46; Natalino Salgado&#59; Centro de Terapia Renal de Itabora&#237; &#40;CTRI&#41;&#58; Dra&#46; Elisa Albuquerque&#59; Centro de Tratamento Renal&#58; Dra&#46; Luc&#237;la Mar&#237;a Valente&#59; Cl&#237;nica de Medicina Interna e Nefrolog&#237;a&#58; Dra&#46; Patr&#237;cia Ferreira Abreu&#59; Cl&#237;nica de Nefrolog&#237;a de Sergipe CLINESE&#58; Dr&#46; Kleyton de Andrade Bastos&#59; Cl&#237;nica de Tratamento Nefrol&#243;gico&#58; Dra&#46; Silvana Mour&#227;o&#59; CLIRE Cl&#237;nica de Doen&#231;as Renais Ltda&#58; Dra&#46; Rosely Riki Matsubara&#59; Dialise do Hospital das Cl&#237;nicas da Faculdade de Medicina de Botucatu&#58; Dra&#46;&#160;Jacqueline Teixeira&#160; Caramori&#59; Funda&#231;&#227;o Oswaldo Ramos&#58; Dra&#46; Maria Eug&#234;nia Fernandes Canziani&#59; GAMEN&#58; Dra&#46;&#160;Maria da Gloria Mesquita Santiago Lima&#59; Hospital Universitario Presidente Dutra HUPD&#58; Dr&#46; Natalino Salgado&#59; Instituto de Doen&#231;as Renais LTDA &#40;Rio Grande do Sul&#41;&#58; Dr&#46; Fernando Saldanha Thom&#233;&#44; Dr&#46; Elvino Barros&#59; Instituto de Hemodi&#225;lise Sorocaba&#58; Dr&#46; Jos&#233; Lu&#237;s Bevilacqua&#59; Instituto do Rim do Paran&#225;&#58; Dr&#46; S&#233;rgio Gardano El&#237;as Bucharles&#59; Renaclin Clinica de Doen&#231;as Renais&#58; Dra&#46; M&#225;rcia Bastos&#59; Unicom - Sociedade de Nefrolog&#237;a Ltda&#58; Dr&#46; Fernando Frattini Neto&#59; Unidade de Tratamento Dial&#237;tico&#58; Dr&#46; Waldir Eduardo Garcia&#46;&#160;<span class="elsevierStyleBold">CHILE&#58;</span> Centro de Di&#225;lisis Cl&#237;nica Antofagasta&#58; Dr&#46; Eric Z&#250;&#241;iga Saravia&#59; Centro de Di&#225;lisis Hospital Cl&#237;nico Fusat&#58; Dra&#46; Anna Mar&#237;a Ar&#233;valo Ar&#233;valo&#59; Centro de Di&#225;lisis Tome Ltda Sucursal Penco&#58; Dr&#46; Jos&#233; Luis L&#243;pez&#44; Dra&#46; Claudia Cerna&#59; Centro de Di&#225;lisis Vallenar Ltda&#58; Dr&#46; Enrique Quintana Meneses&#59; Centro Hemodi&#225;lisis MEDICEN&#58; Dra&#46; Mar&#237;a Eugenia Est&#233;vez Molina&#59; Centro M&#233;dico y Di&#225;lisis TilTil Ltda&#58; Dra&#46; Ana Sota&#59; Centro Nefrol&#243;gico de Di&#225;lisis TOME Ltda&#58; Dra&#46; Mar&#237;a Jos&#233; Aliaga&#44; Dr&#46; Jorge Morente Esquivel&#59; Centro Regional de Di&#225;lisis Araucarias Thno Sucursal Hualpen&#58; Dr&#46; Jaime Lastra Salcedo&#59; Centro Regional de Di&#225;lisis Ltda &#40;Concepci&#243;n&#41;&#58; Dr&#46; Jaime Lastra Salcedo&#59; Centro Salud Anteres SA&#58; Dr&#46; Hern&#225;n E&#46; Echeverr&#237;a Torres&#59; Cl&#237;nica Alemana de Santiago SA&#58; Dr&#46; Enrique Reynolds H&#46;&#59; Cl&#237;nica D&#225;vila&#58; Dr&#46; Claudio Gonz&#225;lez Torres&#59; Cl&#237;nica Las Condes&#58; Dr&#46; Rodrigo Orozco&#59; Corporaci&#243;n Paul Harris&#58; Dr&#46; Antonio Saffie Ib&#225;&#241;ez&#59; Di&#225;lisis &#209;u&#241;oa&#58; Dr&#46; Luis Eduardo Ortiz Brieva&#59; Di&#225;lisis Calama Ltda&#58; Dr&#46; Fernando Gonz&#225;lez&#59; Di&#225;lisis Cl&#237;nica Indisa&#58; Dr&#46; Andr&#233;s Boltansky&#59; Di&#225;lisis Hospital Regional Rancagua&#58; Dr&#46; Juan Romero Tomasevich&#59; Di&#225;lisis Los Andes Ltda&#58; Dr&#46; Juan Lemus&#59; Di&#225;lisis Recoleta&#58; Dra&#46; Mar&#237;a Eugenia Sanhueza&#59; Hospital Carlos Van Buren&#58; Dr&#46; Hugo Poblete Badal&#59; Hospital Dr Hern&#225;n Henr&#237;quez Aravena&#58; Dr&#46; Arturo Pinto Zabaleta&#59; Hospital Exequiel Gonz&#225;lez Cort&#233;s&#58; Dr&#46; Jean Grandy Henr&#237;quez&#59; Hospital Luis Calvo Mackenna&#58; Dra&#46; Ana Mar&#237;a Lillo&#59; Hospital Puerto Natales&#58; Dra&#46; Paulina Folch&#59; Hospital de Coquimbo&#58; Dra&#46; Doris Subiabre Cortes&#59; Hospital Naval Almirante Nef&#58; Dr&#46; Gonzalo Silva Rojas&#59; Rancagua Dial Ltda&#58; Dr&#46; H&#233;ctor Labbe Saffa&#59; Saludial Concepci&#243;n y Saludial Coronel&#58; Dr&#46; Jorge M&#252;nzenmayer B&#59; Sermidial Valparaiso&#58; Dra&#46; Esperanza Merch&#225;n Molina&#59; Sermidial Vi&#241;a del Mar&#58; Dra&#46; Mar&#237;a Carlina Vargas Serrano&#59; Unidad de Di&#225;lisis Hospital Ancud&#58; Dra&#46; Katia Vel&#225;squez Mart&#237;nez&#59; Unidad de Hemodi&#225;lisis Hospital Regional Copiap&#243;&#58; Dr&#46; Guillermo Callejas Gonz&#225;lez&#59; Vitta Dial Los Andes&#58; Dr&#46; Pablo Merch&#225;n C&#243;rdova&#46;&#160;<span class="elsevierStyleBold">COLOMBIA&#58;&#160;</span>Biorrenal&#58; Dr&#46; Jaime Jos&#233; Torres Saltar&#237;n&#46;&#160;<span class="elsevierStyleBold">ECUADOR&#58; </span>Cl&#237;nica de los Ri&#241;ones MENYDIAL&#58; Dr&#46; Dar&#237;o Jim&#233;nez Acosta&#59; Instituto Ecuatoriano de Di&#225;lisis y Trasplante IEDYT&#58; Dr&#46; Fabi&#225;n Ortiz&#58; Herbener&#46; <span class="elsevierStyleBold">HONDURAS&#58;</span> Unidad de Hemodi&#225;lisis IHSS &#40;Tegucigalpa&#41;&#58; Dr&#46; Gaspar Rodr&#237;guez M&#46;<span class="elsevierStyleBold">&#160;M&#201;XICO&#58;</span> Centro Hospitalario la Concepci&#243;n de Saltillo&#58; Dr&#46; Mario Gast&#243;n Melo&#44; Dra&#46; Mar&#237;a Dolores del Bosque Saucedo&#59; Hemodi&#225;lisis Hospital San Jos&#233; Tec de Monterrey&#58; Dr&#46; Alejandro Vald&#233;s Cepeda&#59; Hospital Central Dr&#46; Ignacio Morones Prieto&#58; Dr&#46; Francisco Gerardo Alfaro Abundiz&#44; Dr&#46; Jes&#250;s Mart&#237;nez Reyna&#59; Hospital General Zona &#35; 2&#58; Dr&#46; Alfonso Ramos S&#225;nchez&#59; Hospital Regional de Zona IMSS&#58; Dra&#46; Patricia Mu&#241;oz Sotelo&#59; Hospital Star Medica Morelia&#58; Dr&#46; Eduardo Quintana Pi&#241;a&#59; Hospital Universitario Jos&#233; Eleuterio Gonz&#225;lez&#58; Dr&#46; Edgar Marcelo Arellano Torres&#59; Instituto Mexicano del Seguro Social &#40;IMSS&#41; HGZ N 8&#58; Dr&#46; Javier Pi&#241;&#243;n Escobedo&#59; Instituto de Seguridad y Servicios Sociales de los Trabajadores ISSSTE&#58; Dr&#46; Javier Pi&#241;&#243;n Escobedo&#59; Subsecci&#243;n de Hemodi&#225;lisis Hospital Central Militar&#58; Dr&#46; Ricardo Mendiola Fern&#225;ndez&#44; Dr&#46; Gustavo A&#46; Mart&#237;nez&#59; Unidad de Hemodi&#225;lisis Hospital General Regional No&#46; 25 del IMSS&#58; Dr&#46; Antonio M&#233;ndez Dur&#225;n&#59; Unidad Renal Ambulatoria&#58; Dr&#46; Javier Pi&#241;&#243;n Escobedo&#46;<span class="elsevierStyleBold">&#160;NICARAGUA&#58;&#160;</span>Hospital Salud Integral&#58; Dra&#46; Nubia Cano&#46; <span class="elsevierStyleBold">PANAM&#193;&#58;</span>&#160;Unidad Hospital Susana Jones Cano&#58; Dra&#46; Mar&#237;a Niedda&#46; <span class="elsevierStyleBold">PARAGUAY&#58;</span> Departamento de Nefrolog&#237;a Hospital de Cl&#237;nicas FMC-UNA&#58; Dra&#46; Elvira Gim&#233;nez Rol&#243;n&#59; Hospital Regional Encarnaci&#243;n&#58; Dr&#46; Dar&#237;o Cuevas&#59; Hospital Nacional&#58; Dra&#46; Mar&#237;a Concepci&#243;n R&#237;os&#44; Dra&#46; Miriam L&#243;pez&#59; Servicio de Nefrolog&#237;a Hospital Central de IPSS&#58; Dr&#46; Roger Aureliano Ayala Ferrari&#46;&#160;<span class="elsevierStyleBold">PER&#218;&#58;&#160;</span>Centro Nefrol&#243;gico SA Cenesa&#58; Dr&#46; Le&#243;nidas Carrillo&#59; Hospital Centro M&#233;dico Naval&#58; Dr&#46; Ernesto Valencia Valz&#59; San Fernando SAC&#58; Dr&#46; Pedro Castillo Rodr&#237;guez&#46; <span class="elsevierStyleBold">PUERTO RICO&#58; </span>Hospital Renal Universitario&#58; Dr&#46; Pedro Carlos Pagan Torres&#46;<span class="elsevierStyleBold">&#160;REP&#218;BLICA DOMINICANA&#58;</span> Hospital Regional Dr&#46; Antonio Musa Unidad de Di&#225;lisis&#58; Dra&#46; Sandra Rodr&#237;guez Manzano&#46;&#160;<span class="elsevierStyleBold">URUGUAY&#58;</span> Uruguayana&#58; Dra&#46; Nieves Campistr&#250;s&#59; Asociaci&#243;n M&#233;dica de San Jos&#233;&#58; Dr&#46; Alejandro Ferreiro&#59; Centro de Di&#225;lisis Cr&#243;nica Hospital Maciel&#58; Dra&#46;&#160;Laura Sol&#225;&#59; Centro Nefrol&#243;gico Integral Camedur&#58; Dra&#46; Virginia Matonte&#59; COMERO &#40;Rocha&#41;&#58; Dra&#46; Cecilia Tognola&#59; COMEPA&#58; Dra&#46; Mariela Odriozola&#44; Dra&#46; Marta Pereyra&#44; Dra&#46;&#160;Marcela Daglio&#59; Di&#225;lisis del Hospital Brit&#225;nico&#58; Dr&#46; Juan Fern&#225;ndez Cean&#44; Dra&#46; Catalina Guti&#233;rrez&#59; INU&#58; Dra&#46; Enriqueta Carbonell&#59; SARI- IBIRAPITA&#58; Dra&#46; Alicia Petraglia&#44; Dra&#46; Anal&#237;a Varela&#59; SE&#46;NE&#46;C&#46;C&#46; &#40;Centro de Di&#225;lisis de COMECA&#41;&#58; Dra&#46; Lydia Zampedri&#59; Unidad CEDINA&#58; Dr&#46; Juan Carlos D&#237;az&#44; Dra&#46; Aquelina &#193;lvarez&#46;&#160;<span class="elsevierStyleBold">VENEZUELA&#58;</span> Unidad Hospital N&#250;&#241;ez Tovar&#58; Dr&#46; Carlos M&#225;rquez&#44; Dr&#46; Andr&#233;s Cortez&#59; Hospital Universitario de Los Andes M&#233;rida&#58; Dr&#46; Bernardo Fargier&#44; Dra&#46; Dulce Winterdaal&#59; Di&#225;lisis San Antonio CA&#58; Dr&#46; Silvano Vernamonte Damiani&#59; Unidad de Di&#225;lisis GAPB Guatire&#58; Dr&#46; Leoncio Serrano&#59; Unidad de Di&#225;lisis Hospital Militar Caracas&#58; Dr&#46; Leoncio Serrano Centro M&#233;dico Docente La Trinidad&#58; Dra&#46; Ana Mar&#237;a San&#225;nez&#59; Centro Nefrol&#243;gico Integral Falc&#243;n&#58; Dr&#46; Ram&#243;n Polanco&#59; Hospital de Cl&#237;nicas Caracas&#58; Dra&#46; Julia Bravo&#44; Dra&#46; Leonor Oliveros&#44; Dr&#46; Pablo Amair&#59; Servicios Nefrol&#243;gicos CA&#58; Dra&#46; Belquis Chuecos&#59; Unidad de Hemodi&#225;lisis Naguanagua&#58; Dr&#46; David L&#243;pez&#44; Dr&#46; Orleans M&#233;ndez&#59; Unidad de Hemodi&#225;lisis Jes&#250;s de Nazareno CA N 1&#58; Dra&#46; Silvia Villarroel&#59; Unidad de Hemodi&#225;lisis Jes&#250;s de Nazareno CA N 2&#58; Dra&#46; Silvia Villarroel&#59; Unidad Di&#225;lisis M&#233;rida &#40;DIAMERCA&#41;&#58; Dr&#46; Bernardo Fargier&#44; Dr&#46; Luis Guilarte&#46;&#160;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interest</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">The authors declare that there is no conflict of interest associated with this manuscript&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12234&#95;19904&#95;49638&#95;en&#95;12234&#95;16025&#95;49638&#95;en&#95;t112234&#46;jpg" class="elsevierStyleCrossRefs"><img src="12234_19904_49638_en_12234_16025_49638_en_t112234.jpg" alt="Baseline demographic and clinical characteristics of 9&#44;025 Latin American hemodialysis patients&#46;"></img></a></p><p class="elsevierStylePara">Table 1&#46; Baseline demographic and clinical characteristics of 9&#44;025 Latin American hemodialysis patients&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12234&#95;19904&#95;49642&#95;en&#95;12234&#95;16025&#95;49642&#95;en&#95;t212234&#46;jpg" class="elsevierStyleCrossRefs"><img src="12234_19904_49642_en_12234_16025_49642_en_t212234.jpg" alt="Anemia treatment in 9&#44;025 Latin American hemodialysis patients&#46;"></img></a></p><p class="elsevierStylePara">Table 2&#46; Anemia treatment in 9&#44;025 Latin American hemodialysis patients&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12234&#95;19904&#95;49643&#95;en&#95;12234&#95;16025&#95;49643&#95;en&#95;f112234&#46;jpg" class="elsevierStyleCrossRefs"><img src="12234_19904_49643_en_12234_16025_49643_en_f112234.jpg" alt="Distribution of the hemoglobin levels by the participating countries&#46;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Distribution of the hemoglobin levels by the participating countries&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12234&#95;19904&#95;49645&#95;en&#95;12234&#95;16025&#95;49645&#95;en&#95;t312234&#46;jpg" class="elsevierStyleCrossRefs"><img src="12234_19904_49645_en_12234_16025_49645_en_t312234.jpg" alt="Associations between anemia management variables and hemoglobin levels&#46;"></img></a></p><p class="elsevierStylePara">Table 3&#46; Associations between anemia management variables and hemoglobin levels&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Antecedentes&#58; </span>La anemia representa una complicaci&#243;n frecuente en pacientes con enfermedad renal cr&#243;nica&#46; En Latinoam&#233;rica &#40;LA&#41; la prevalencia y caracter&#237;sticas de la anemia en pacientes en hemodi&#225;lisis &#40;HD&#41; no ha sido bien estudiada&#46; <span class="elsevierStyleBold">Objetivo&#58; </span>Evaluar los resultados del primer registro de anemia del Comit&#233; de Anemia de la Sociedad Latinoamericana de Nefrolog&#237;a e Hipertensi&#243;n&#46; <span class="elsevierStyleBold">M&#233;todos&#58; </span>Esta es una encuesta multinacional&#44; voluntaria&#44; que recolect&#243; datos sobre el tratamiento de la anemia en pacientes en HD de unidades independientes en LA entre septiembre de 2009 y marzo de 2010&#46; Para el an&#225;lisis estad&#237;stico se utilizaron los siguientes m&#233;todos&#58; t-test&#44; ANOVA&#44; chi<span class="elsevierStyleSup">2</span> y el an&#225;lisis de regresi&#243;n log&#237;stica multivariante&#46; <span class="elsevierStyleBold">Resultados&#58;</span> La encuesta fue respondida por 134 unidades de HD de 16 pa&#237;ses&#44; recibi&#233;ndose datos de 9025 pacientes&#46; Las medias &#177; desviaci&#243;n est&#225;ndar de Hb&#44; ferritina y del &#237;ndice de saturaci&#243;n de transferrina &#40;IST&#41; fueron respectivamente&#58; 10&#44;5 &#177; 1&#44;8 g&#47;dl&#44; 570 &#177; 539 &#181;g&#47;l y 29&#44;8&#160;&#37; &#177; 15&#46; Se administr&#243; agentes estimulantes de la eritropoyesis &#40;AEE&#41; al 84&#44;3&#160;&#37; de los pacientes y hierro intravenoso &#40;FeIV&#41; al 68&#44;3&#160;&#37;&#46; Solamente el 32&#44;7&#160;&#37; de los pacientes tuvieron una Hb blanco de 10&#44;5-12&#44;0 g&#47;dl&#46; En pacientes con Hb &#60;&#160;10&#44;5 g&#47;dl&#44; el 85&#44;2&#160;&#37; estaban recibiendo AEE y un 68&#160;&#37; FeIV&#46; Las variables independientes asociadas con nivel Hb &#60;&#160;10&#44;5 g&#47;dl fueron&#58; g&#233;nero femenino&#44; IST&#160;&#60;&#160;25&#160;&#37; y edad &#60;&#160;50 a&#241;os&#46;&#160; En la muestra de pacientes analizada&#44; a pesar del amplio uso de los AEE y FeIV&#44; casi la mitad de los pacientes no alcanz&#243; la Hb blanco&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Background&#58; </span>Anemia almost invariably occurs in patients with chronic kidney disease&#46; Limited data are available regarding anemia management in Latin American &#40;LA&#41; hemodialysis &#40;HD&#41; patients&#46; <span class="elsevierStyleBold">Objective</span>&#58; To evaluate the results of the first anemia survey of the Anemia Committee of the SLANH&#46; <span class="elsevierStyleBold">Methods&#58;</span> This is a multinational&#44; voluntary survey that collected anemia management data from adult HD patients from independent&#44; non-chain owned HD units&#44; between 09&#47;2009 and 03&#47;2010&#46; T-test&#44; ANOVA&#44; chi-square test and multivariate logistic regression were used for statistical analysis&#46; <span class="elsevierStyleBold">Results&#58; </span>The survey received responses from 134 HD units of 16 countries providing data from 9&#44;025 patients&#46; Mean values of Hb&#44; ferritin&#44; and transferrin saturation &#40;TSAT&#41; were 10&#46;5&#177;1&#46;8g&#47;dL&#44; 570&#177;539&#181;g&#47;l&#44; and 29&#46;8&#177;15&#37;&#44; respectively&#46; Only 32&#46;7&#37; of patients were within the Hb target of 10&#46;5-12&#46;0g&#47;dL &#40;46&#46;3&#37; were below and 21&#46;1&#37; above&#41;&#46; Erythropoietin-stimulating agents &#40;ESAs&#41; were administered to 84&#46;3&#37; patients and 68&#46;3&#37; received intravenous iron &#40;IV&#41;&#46; Iron deficiency &#40;TSAT&#8804;20&#37;&#41; was present in 27&#46;5&#37; patients and among those receiving erythropoietin&#44; 47&#37; did not achieve Hb target&#46; The independent variables associated with the lowest Hb level &#40;&#60;10&#46;5g&#47;dL&#41; were&#58; female gender&#44; TSAT¿25&#37; and age&#60;50 years&#46; <span class="elsevierStyleBold">Conclusions&#58; </span>According to these results&#44; nearly half of LA chronic HD patients did not achieve the recommended Hb target despite wide use of ESAs and IV iron&#46;</p>"
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ISSN: 20132514
Original language: English
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