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

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.