Evaluation and Determinants of Underprescription of Erythropoiesis Stimulating Agents in Pre-Dialysis Patients with Anaemia

Abstract

Background: Inadequate anaemia correction (haemoglobin (Hb) <11 g/dl without receiving an erythropoiesis-stimulating agent (ESA) is common in pre-dialysis patients, but little is known about its determinants. We used data from the French end-stage renal disease (ESRD) registry to investigate these determinants and the patients’ anaemia status 1 year after starting dialysis. Methods: Pre-dialysis anaemia care was studied in 6,271 incident ESRD patients from 13 regions, who were first treated between 2003 and 2005. Data included pre-dialysis Hb measure and ESA use, patient’s condition and modalities of dialysis initiation. Anaemia status at 1 year was studied in 925 patients from four regions who started dialysis in 2003 and 2004, were still on dialysis one year later, and had completed the annual registry data form. Results: Overall, 34.7% of the patients had inadequate pre-dialysis anaemia correction, with variations across regions from 21.1 to 43.2%. Inadequate anaemia correction decreased from 38.0% in 2003 to 33.2% in 2005. It was less likely in patients with diabetic or polycystic kidney disease and more likely in those with malignancy, unplanned haemodialysis, and low glomerular filtration rate or low serum albumin at dialysis initiation. One year after starting dialysis, inadequate correction concerned only 2.6% of the patients. Hb level had risen from 10.3 g/dl in pre-dialysis to 11.7 g/dl, but remained lower in those with inadequate pre-dialysis correction. Conclusion: Despite improvement over time, inadequate correction with ESAs remains high in pre-dialysis patients in contrast with those on dialysis. As the timing of dialysis initiation is uncertain, continuous management of anaemia is requested.

Chronic kidney disease: appropriateness of therapeutic management and associated factors in the AVENIR study

“…Good management of anaemia in CKD patients has been shown to be associated with decreased morbidity and mortality [24] and a reduced occurrence of cardiovascular complications [25]. Anaemia care was suboptimal here, with appropriate management in 56.2% of cases, but much better than that found in other studies [4,9,10,12]. For example, Bailie et al reported that only 20% of patients with stages 2-5 CKD were receiving epoetin therapy and 13% iron at the time of enrolment [9].…”

“…Despite the availability since 1997 of guidelines from the National Kidney Foundation describing how to manage CKD patients, the literature shows that insufficient attention is being paid to the issues outlined above [2][3][4][5][6][7][8][9][10][11][12]. However, most studies reported to date have evaluated the quality of care with reference to no more than a few co-morbid conditions or complications, sometimes only one.…”

Hemoglobin Variability Does Not Predict Mortality in European Hemodialysis Patients

“…This could be due to incident patients experiencing a slight increase in Hb levels during the exposure period, presumably because most of them did not receive ESAs before initiation of dialysis. 15 The higher level of variability may also be explained by a higher prevalence of comorbidities among incident patients. 16 Our findings for residual SD were relatively consistent with previously reported findings.…”

Profil des insuffisants rénaux chroniques diabétiques à l’initiation de l’hémodialyse au service de néphrologie et dialyse de l’hôpital militaire de Rabat, Maroc

“…Sur le registre REIN en 2006, 2 patients sur 3 en IRCT avaient un taux d'hémoglobine inférieur à 11 g/dl à l'initiation du traitement, en dépit de l'accessibilité à l’érythropoïétine, qu'ils soient ou non diabétiques [ 8 , 15 ]. De même que dans une étude précédente [ 16 ], en France, il n'a pas été mis en évidence de lien entre le statut diabétique et l'importance de l'anémie, contrairement à ce qui a pu être observé dans l’étude ACORD (The Anaemia CORrection in Diabetes) [ 17 ]. Le taux de ferritinémie significativement plus bas chez les diabétiques de notre série pourrait y contribuer de sa part (267 ng/ml vs. 343 ng/ml, p= 0,04).…”