Knowledge-based clinical decision support system for the automated classification of anemia in hemodialysis patients
Abstract
Introduction. Anemia is a frequent complication in patients with chronic kidney disease undergoing hemodialysis and is associated with increased morbidity, mortality, and healthcare burden. Accurate classification is essential to optimize treatment with intravenous iron and erythropoiesis-stimulating agents. Rule-based clinical decision support systems (CDSS) provide a strategy to standardize this process.
Objective. To describe the development and implementation of a knowledge-based clinical decision support system for the automated classification of anemia in hemodialysis patients using laboratory data.
Materials and methods. This retrospective observational study included 883 adult patients receiving prevalent hemodialysis during 2023. An algorithm was developed based on established clinical guidelines [Sociedad Latinoamericana de Nefrología e Hipertensión (SLANH)], KDIGO, NICE to classify patients with hemoglobin below 12 g/dl into three categories: absolute iron deficiency, functional iron deficiency, and candidates for therapeutic trial with intravenous iron. The system also flagged cases with suspected severe secondary hyperparathyroidism (PTH > 800 pg/ml). Data was obtained from the laboratory information system and the clinical decision support system. We applied a descriptive statistical analysis.
Results. The clinical decision support system automatically classified patients into the following categories: functional iron deficiency (39.2%), severe hyperparathyroidism (26.7%), absolute iron deficiency (17.7%), and candidates for intravenous iron trial (16.4%). A subgroup (9.5% within the functional iron deficiency group) also showed elevated PTH levels, suggesting potential resistance to erythropoiesis-stimulating agents. Distinct clinical profiles were observed across the groups.
Conclusions. The clinical decision support system enabled automated and standardized classification of anemia in hemodialysis patients, supporting evidence-based clinical decision-making. Its implementation represents a digital health innovation with the potential to improve the quality and safety of anemia management in chronic kidney disease.
Downloads
References
Jager KJ, Kovesdy C, Langham R, Rosenberg M, Jha V, Zoccali C. A single number for advocacy and communication—Worldwide more than 850 million individuals have kidney diseases. Kidney Int. 2019;96:1048-50. https://doi.org/10.1016/j.kint.2019.07.012
Foreman KJ, Márquez N, Dolgert A, Fukutaki K, Fullman N, McGaughey M, et al. Forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death. Lancet. 2018;392:2052-90. https://doi.org/10.1016/S0140-6736(18)31694-5
Cuenta de Alto Costo. Día mundial del riñón 2022. Fecha de consulta: 17 de mayo de 2024. Disponible en: https://cuentadealtocosto.org/erc/dia-mundial-del-rinon-2022/
Cases A, Egocheaga MI, Tranche S, Pallarés V, Ojeda R, Górriz JL, et al. Anemia of chronic kidney disease: Protocol of study, management and referral to Nephrology. Nefrologia. 2018;38:8-21. https://doi.org/10.1016/j.nefro.2017.05.001
López-Gómez JM, Abad S, Vega A. New expectations in the treatment of anemia in chronic kidney disease. Nefrologia. 2016;36:232-6. https://doi.org/10.1016/j.nefro.2016.03.002
Farrington DK, Sang Y, Grams ME, Ballew SH, Dunning S, Stempniewicz N, et al. Anemia prevalence, type, and associated risks in a cohort of 5.0 million insured patients. Am J Kidney Dis. 2023;81:201-9.e1. https://doi.org/10.1053/j.ajkd.2022.08.006
Floege J, Feehally J, Johnson RJ, Tonelli O. Comprehensive Clinical Nephrology. 6th edition. Philadelphia: Elsevier; 2019. p. 1312.
Hain D, Bednarski D, Cahill M, Dix A, Foote B, Haras MS, et al. Iron-deficiency anemia in CKD: A narrative review. Kidney Med. 2023;5:100524. https://doi.org/10.1016/j.xkme.2023.100677
Carlini R, Obrador G, Campistrús N, Andrade L, Chifflet L, Bregman R, et al. First report of the SLANH anemia committee in chronic hemodialysis patients. Nefrologia. 2014;34:96-104. https://doi.org/10.3265/nefrologia.pre2013.oct.12234
Sutton RT, Pincock D, Baumgart DC, Sadowski DC, Fedorak RN, Kroeker KI. An overview of clinical decision support systems: Benefits, risks, and strategies for success. NPJ Digit Med. 2020;3:17. https://doi.org/10.1038/s41746-020-0221-y
Stevens PE, Ahmed SB, Carrero JJ, Foster B, Francis A, Hall RK, et al. KDIGO 2024 clinical practice guideline for CKD. Kidney Int. 2024;105(Suppl. 4):S117-314. https://doi.org/10.1016/j.kint.2023.10.018
Batchelor EK, Kapitsinou P, Pergola PE, Kovesdy CP, Jalal DI. Iron deficiency in chronic kidney disease: Updates on pathophysiology, diagnosis, and treatment. J Am Soc Nephrol. 2020;31:456–68. https://doi.org/10.1681/ASN.2019020213
Gryglewski RW, Deptała A, Podolak-Dawidziak M, Dwilewicz-Trojaczek J, Walewski J, Jurczyszyn A. Erythropoietin: Discovery with Polish contribution. Pol Arch Intern Med. 2021;131:317-9. https://doi.org/10.20452/pamw.15909
Gupta N, Wish JB. Erythropoietin and its cardiovascular effects. In: Ronco C, editor. Cardio-Nephrology. Cham: Springer; 2017. p. 119-28. https://doi.org/10.1007/978-3-319-56042-7_11
Andrade L, Blanco C, Chifflet L, Cruz de Trujillo ZC, Fernandes Canziani ME, Forster TA, et al. Recomendaciones para el estudio y tratamiento de la anemia en pacientes con enfermedad renal crónica. 2018. Fecha de consulta: 17 de mayo de 2024. Disponible en: https://slanh.net/wp-content/uploads/2021/12/recomendaciones_-anemia_version_corregida_agosto_2018.pdf
Petzer V, Tymoszuk P, Asshoff M, Carvalho J, Papworth J, Deantonio C, et al. Anti-BMP6 antibody reduces erythropoietin need in rodents. Blood. 2020;136:1080-91. https://doi.org/10.1182/blood.2019004653
Kim DH, Lee YK, Kim J, Park HC, Yun KS, Cho A, et al. Effects of the route of erythropoietin administration on hemoglobin variability and cardiovascular events in hemodialysis patients. Kidney Res Clin Pract. 2021;40:724-33. https://doi.org/10.23876/j.krcp.20.260
Kamei D, Tsuchiya K, Miura H, Nitta K, Akiba T. Inter-method variability of ferritin and transferrin saturation measurement methods in patients on hemodialysis. Ther Apher Dial. 2017;21:43-51. https://doi.org/10.1111/1744-9987.12479
Dignass A, Farrag K, Stein J. Limitations of serum ferritin in inflammatory conditions. Int J Chron Dis. 2018;2018:9394060. https://doi.org/10.1155/2018/9394060
Macdougall IC, White C, Anker SD, Bhandari S, Farrington K, Kalra PA, et al. Intravenous iron in hemodialysis. N Engl J Med. 2019;380:447-58. https://doi.org/10.1056/NEJMoa1810742
Mark PB, Jhund PS, Walters MR, Petrie MC, Power A, White C, et al. Stroke in hemodialysis patients randomized to different intravenous iron strategies: A prespecified analysis from the PIVOTAL trial. Kidney360. 2021;2:1761-9. https://doi.org/10.34067/KID.0004272021
Liu L, Cheng H, Lv Y, Yu W, Liu Q, Wu Y, et al. High-dose versus low-dose iron sucrose in individuals undergoing maintenance haemodialysis: A retrospective study. BMC Nephrol. 2021;22:350. https://doi.org/10.1186/s12882-021-02570-0
Petrie MC, Jhund PS, Connolly E, Mark PB, MacDonald MR, Robertson M, et al. High-doce intravenous iron reduces myocardial infarction in patients on haemodialysis. Cardiovasc Res. 2023;119:213-20. https://doi.org/10.1093/cvr/cvab317
Singh AT, Yen TE, Mothi SS, Waikar SS, Mc Causland FR. Associations of iron sucrose and intradialytic blood pressure. Am J Kidney Dis. 2023;81:647-54. https://doi.org/10.1053/j.ajkd.2022.11.007
Barbieri C, Molina M, Ponce P, Tothova M, Cattinelli I, Titapiccolo JI, et al. An international observational study suggests that artificial intelligence for clinical decision support optimizes anemia management in hemodialysis patients. Kidney Int. 2016;90:422-9. https://doi.org/10.1016/j.kint.2016.03.036
Samal L, Kilgallon JL, Lipsitz S, Baer HJ, McCoy A, Gannon M, et al. Clinical decisión support for hypertension management in chronic kidney disease: A randomized clinical trial. JAMA Intern Med. 2024;184:484-92. https://doi.org/10.1001/jamainternmed.2023.8315
Carroll JK, Pulver G, Dickinson LM, Pace WD, Vassalotti JA, Kimminau KS, et al. Effect of 2 clinical decision support strategies on chronic kidney disease outcomes in primary care: A cluster randomized trial. JAMA Netw Open. 2018;1:e183377. https://doi.org/10.1001/jamanetworkopen.2018.3377
Grechuta K, Shokouh P, Alhussein A, Müller-Wieland D, Meyerhoff J, Gilbert J, et al. Benefits of clinical decision support systems for the management of noncommunicable chronic diseases: Targeted literature review. Interact J Med Res. 2024;13:e58036. https://doi.org/10.2196/58036
Some similar items:
- Rosa Magdalena Uscátegui, Adriana M. Correa, Jaime Carmona-Fonseca, Changes in retinol, hemoglobin and ferritin concentrations in Colombian children with malaria , Biomedica: Vol. 29 No. 2 (2009)
- Elpidia Poveda, Alexandra Cuartas, Saralicia Guarín, Yibby Forero, Elsa Villarreal, Iron and vitamin A micronutrient status, risk factors for their deficiencies and anthropometric assessment in preschool child from Funza municipality, Colombia , Biomedica: Vol. 27 No. 1 (2007)
- Margarita Arboleda, María Fernanda Pérez, Diana Fernández, Luz Yaned Usuga, Miler Meza, Clinical and laboratory profile of Plasmodium vivax malaria patients hospitalized in Apartadó, , Biomedica: Vol. 32 (2012): Suplemento 1, Malaria
- Beatriz Elena Parra, Luz Mariela Manjarrés, Alba Lucía Gómez, Dora María Alzate, María Clemencia Jaramillo, Assessment of nutritional education and iron supplement impact on prevention of pregnancy anemia. , Biomedica: Vol. 25 No. 2 (2005)
- Ángela Medina, David López, Luis Reinel Vásquez, Severe pediculosis capitis in a nursery school girl , Biomedica: Vol. 39 No. 4 (2019)
- Ruth Eraso, Claudia Patricia Benítez , Sergio Jaramillo , Jorge Acosta-Reyes , Beatriz Helena Aristizábal , Augusto Quevedo , Ferritin levels in children with juvenile idiopathic arthritis of systemic onset and children with other causes of fever of unknown origin: A multicenter study of diagnostic tests , Biomedica: Vol. 41 No. 4 (2021)
- Carlos Julio Vargas-Potes, Diana Marcela Mendoza-Urbano, Luis Gabriel Parra-Lara , Ángela R. Zambrano, Challenges in the care of Ewing’s sarcoma in a Jehovah’s Witness patient , Biomedica: Vol. 43 No. 1 (2023)
- Iván Peña, Juan Sarmiento, Cristian Porras, Ximena Cediel , Ana Camargo, Myelopathy due to copper deficiency: A case series and review of the literature , Biomedica: Vol. 43 No. 2 (2023)
- Luis David Moreno, Carlos Eduardo Ruiz , Juan Carlos Urrego , Miguel Oswaldo Cadena, Silvia José Maldonado, Daniel Andrés Niño , Andrea Maldonado , Frailty syndrome and end-stage kidney disease outcomes at a Latin American dialysis center , Biomedica: Vol. 43 No. Sp. 3 (2023): Enfermedades crónicas no transmisibles
- A Puerto, Nelson Rafael Alvis-Zakzuk, Walter Annicchiarico, Nelson Alvis-Guzmán, J Zakzuk, Relationship between serum ferritin and proinflammatory markers in late pregnancy: An exploratory analysis from Cartagena, Colombia , Biomedica: Vol. 45 No. 1 (2025)
Copyright (c) 2025 Biomedica
This work is licensed under a Creative Commons Attribution 4.0 International License.
| Article metrics | |
|---|---|
| Abstract views | |
| Galley vies | |
| PDF Views | |
| HTML views | |
| Other views | |
