Anemia Management in Non-dialysis CKD Patients

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Anemia Management in Non-dialysis CKD Patients

Abstract and Introduction


Background. Knowledge on anaemia management in non-dialysis chronic kidney disease (ND-CKD) patients regularly followed in renal clinics is scarce although being essential to identifying areas of therapeutic improvement.

Methods. We prospectively evaluated anaemia management in two visits, performed 6 months apart, in 755 prevalent ND-CKD stage 3b-5 patients followed in 19 nephrology clinics from ≥6 months. Anaemia was defined as severe (Hb <11 g/dL) or mild (Hb: 11–13.5 in males and 11–12 g/dL in females); iron deficiency (ID) was defined as transferrin saturation (TSAT) <20% and/or ferritin <100 ng/mL. Primary endpoint was the change of anaemia and ID prevalence between baseline and 6-month visit. Secondary endpoint was the prevalence of clinical inertia to either ESA or iron supplementation, that is, the lack of ESA or iron prescription despite Hb <11 g/dL or ID.

Results. Age was 69 ± 13 years and GFR 27.5 ± 10.0 mL/min/1.73 m; male gender, diabetes and prior cardiovascular disease were 57.2, 30.1 and 30.1%, respectively. Prevalence of severe and mild anaemia was 18.0 and 44.0% at baseline and remained unchanged at Month 6 (19.3 and 43.2%). ID was prevalent at both visits (60.1 and 60.9%). Clinical inertia to ESA was similar at baseline and at Month 6 (39.6 and 34.2%, respectively, P = 0.487) and it was less frequent than clinical inertia to iron therapy (75.7 and 72.0%, respectively).

Conclusions. This study shows that anaemia prevalence is unexpectedly high in the setting of tertiary nephrology care. This was due to a persistent clinical inertia in the anaemia management, remarkable for iron supplementation and less critical, but still significant, for ESA treatment.


Non-dialysis chronic kidney disease (ND-CKD) is a major area to focus on for nephrologists to delay ESRD and reduce the associated high cardiovascular risk. Noteworthy, in diabetic patients with moderate-to-severe CKD, mortality is lower in those steadily followed in nephrology clinics than in patients regularly followed by either a cardiologist or endocrinologist, likely because of better control of traditional and non-traditional risk factors. In this picture, anaemia emerges as a main independent modifiable risk factor of cardiovascular and renal damage. Despite the clinical relevance of this issue, very few studies have extensively assessed how anaemia is managed in renal clinics. The need for updated and comprehensive information on anaemia management is further supported by three reasons. First, strategies for guidelines implementation require the knowledge of how anaemia is currently managed in clinical practice. This is particularly important for physicians when findings derived from selected cohorts of randomized clinical trials (RCTs) have to be implemented in an unselected CKD population requiring individualization strategy, based on the patient's comorbidities, life activity and symptoms. Secondly, a prescription pattern of anti-anaemic drugs is rapidly changing in response to the negative findings of RCTs on anaemia control Indeed, data from USRDS have recently evidenced a progressive reduction in Hb levels since 2006, in the presence of reducing ESA prescription and increasing iron use, and an increased risk of blood transfusion and hospitalization. The implementation of the more restrictive KDIGO recommendations could exacerbate this trend. Thirdly, knowledge of anaemia medication patterns use allows identifying opportunities for improving care. Moreover, identification of anaemia treatment patterns in nationally representative outpatient nephrology settings may also help to design an evidence-based algorithm by identifying the variations in physician prescriptions for ND-CKD and the reasons for such variations.

We, therefore, studied a prospective cohort of prevalent ND-CKD patients under nephrology care from at least 6 months prior to baseline in 19 Italian renal clinics. Data were collected in two visits with a 6-month interval to evaluate current management of renal anaemia in CKD and to identify potential areas of therapeutic improvement in terms of ESA and iron use.

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