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Vol. 108, No. 1, 2008
Issue release date: February 2008
Nephron Clin Pract 2008;108:c67–c74

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

Thilly N. · Stengel B. · Boini S. · Villar E. · Couchoud C. · Frimat L.
aDepartment of Clinical Epidemiology and Evaluation, CEC-CIE6 Inserm, University Hospital of Nancy, EA4003, Nancy University, Nancy, bInserm U780, Research in Epidemiology and Biostatistics, Villejuif, cDepartment of Nephrology and Renal Transplantation and Department of Biostatistics, UMR CNRS 5558, Hospices Civils de Lyon, Lyon-Sud Academic Hospital, Pierre Bénite, dREIN Registry, Agence de la Biomédecine, La Plaine Saint Denis, and eDepartment of Nephrology, Hôpitaux de Brabois, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France

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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.

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Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
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  1. Locatelli F, Pisoni RL, Combe C, Bommer J, Andreucci VE, Piera L, Greenwood R, Feldmann HI, Port FK, Held PJ: Anaemia in haemodialysis patients in five European countries: association with morbidity and mortality in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant 2004;19:121–132.
  2. Rao M, Pereira BJ: Optimal anaemia management reduces cardiovascular morbidity, mortality, and costs in chronic kidney disease. Kidney Int 2005;68:1432–1438.
  3. National Kidney Foundation Dialysis Outcomes Quality Initiative: KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anaemia in Chronic Kidney Disease. Am J Kidney Dis 2006;47(suppl 3):S11–S145.
  4. Locatelli F, Aljama P, Barany P, Canaud B, Carrera F, Eckardt KU, Horl WH, Macdougall IC, Macleod A, Wiecek A, Cameron S, European Best Practice Guidelines Working Group: Revised European best practice guidelines for the management of anaemia in patients with chronic renal failure. Nephrol Dial Transplant 2004;19(suppl 2):S1–S47.
  5. Drueke TB, Locatelli F, Clyne N, Eckardt KU, Macdougall IC, Tsakiris D, Burger HU, Scherhag A, CREATE Investigators: Normalization of hemoglobin level in patients with chronic kidney disease and anemia. N Engl J Med 2006;355:2071–2084.
  6. Singh AK, Szczech L, Tang KL, Barnhart H, Sapp S, Wolfson M, Reddan D, CHOIR Investigators: Correction of anemia with epoetin alfa in chronic kidney disease. N Engl J Med 2006;355:2085–2098.
  7. Obrador GT, Ruthazer R, Arora P, Kausz AT, Pereira BJ: Prevalence of and factors associated with suboptimal care before initiation of dialysis in the United States. J Am Soc Nephrol 1999;10:1793–1800.
  8. Obrador GT, Roberts T, St Peter WL, Frazier E, Pereira BJG, Collins AJ: Trends in anaemia at initiation of dialysis in the United States. Kidney Int 2001;60:1875–1884.
  9. Owen WF Jr: Patterns of care for patients with chronic kidney disease in the United States: dying for improvement. J Am Soc Nephrol 2003;14(suppl 2):S76–S80.

    External Resources

  10. Jungers PY, Robino C, Choukroun G, Nguyen-Khoa T, Massy ZA, Jungers P: Incidence of anaemia, and use of epoietin therapy in predialysis patients: a prospective study in 403 patients. Nephrol Dial Transplant 2002;17:1621–1627.
  11. De Nicola L, Minutolo R, Chiodini P, Zoccali C, Costellini P, Donadio C, Strippoli M, Casino F, Giannattasio M, Petrarulo F, Virgilio M, Laraia E, Di Iorio BR, Savica V, Conte G, TArget Blood Pressure LEvels in Chronic Kidney Disease (TABLE in CKD) Study Group: Global approach to cardiovascular risk in chronic kidney disease: reality and opportunities for intervention. Kidney Int 2006;69:538–545.
  12. Valderrabano F, Horl WH, Macdougall IC, Rossert J, Rutkowski B, Wauters JP: PRE-dialysis survey on anaemia management. Nephrol Dial Transplant 2003;18:89–100.
  13. McClellan WM, Jurkovitz C, Abramson J: The epidemiology and control of anaemia among pre-ESRD patients with chronic kidney disease. Eur J Clin Invest 2005;35(suppl 3):58–65.
  14. Burton C, Ansell D, Taylor H, Dunn E, Feest T: Management of anaemia in United Kingdom renal units: a report from the UK Renal Registry. Nephrol Dial Transplant 2000;15:1022–1028.
  15. Pisoni RL, Bragg-Gresham JL, Young EW, Akizawa T, Asano Y, Locatelli F, Bommer J, Cruz JM, Kerr PG, Mendelssohn DC, Held PJ, Port FK: Anaemia management and outcomes from 12 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2004;44(suppl 1):94–111.

    External Resources

  16. Saudan P, Halabi G, Perneger T, Wasserfallen JB, Kossovsky M, Feldman H, Martin PY, Wauters JP, Western Switzerland Dialysis Study Group: Variability in quality of care among dialysis units in western Switzerland. Nephrol Dial Transplant 2005;20:1854–1863.
  17. Bannister KM, Snelling P: National haemodialysis guidelines: an assessment of compliance from 2001–2003. Nephrology2006;11:90–96.
  18. United States Renal Data System: 2003 annual report: ESRD clinical performance measures project. Am J Kidney Dis 2004;44 (suppl 1):S4–S58.
  19. Couchoud C, Stengel B, Landais P, Aldigier JC, de Cornelissen F, Dabot C, Maheut H, Joyeux V, Kessler M, Labeeuw M, Isnard H, Jacquelinet C: The renal epidemiology and information network (REIN): a new registry for end-stage renal disease in France. Nephrol Dial Transplant 2006;21:411–418.
  20. Levey AS, Coresh J, Balk E, Kausz AT, Levin A, Steffes MW, Hogg RJ, Perrone RD, Lau J, Eknoyan G for the National Kidney Foundation: National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification and stratification. Ann Intern Med 2003;139:137–147.
  21. Steinbrook R: Haemoglobin concentrations in chronic kidney disease. Lancet 2006;368:2191–2193.
  22. Kessler M, Frimat L, Panescu V, Briançon S: Impact of nephrology referral on early and mid-term outcomes in ESRD: EPidémiologie de l’Insuffisance REnale chronique terminale en Lorraine (EPIREL): Results of a 2-year prospective, community-based study. Am J Kidney Dis 2003;42:474–485.
  23. Thilly N, Boini S, Kessler M, Briançon S, Frimat L: Nephrology referral and appropriateness of therapeutic drugs care in chronic kidney disease. J Nephrol 2006;19:303–311.
  24. Hsu CY, Bates DW, Kuperman GJ, Curhan GC: Relationship between hematocrit and renal function in men and women. Kidney Int 2001;59:725–731.
  25. Wang AY, Lai KN: The importance of residual renal function in dialysis patients. Kidney Int 2006;69:1726–1732.
  26. Ritz E: Managing anaemia and diabetes: a future challenge for nephrologists. Nephrol Dial Transplant 2005;20(suppl 6):VI21–25.
  27. Nivet H, Maingourd C, Mignon F: Démographie des néphrologues en France en 2002. Néphrologie 2003;24:431–436.
  28. Jacobs C, Frei D, Perkins AC: Results of the European Survey on Anaemia Management 2003 (ESAM 2003): current status of anaemia management in dialysis patients, factors affecting epoetin dosage and changes in anaemia management over the last 5 years. Nephrol Dial Transplant 2005;20(suppl 3):III3–III24.

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