SO053A REAL WORLD LONGITUDINAL ANALYSIS OF ANAEMIA TREATMENT PRESCRIPTIONS IN NON-DIALYSIS-DEPENDENT CHRONIC KIDNEY DISEASE PATIENTS, A CKDOPPS STUDY
Authors: Lopes Marcelo , Tu Charlotte , Zee Jarcy , Foote Bryce , Guedes Murilo , Hedman Katarina , James Glen , Lopes Antonio Alberto , Massy Ziad , Reichel Helmut , Pisoni Ronald , Sloand James , Waechter Sandra , Wong Michelle , Robinson Bruce , Pecoits-Filho Roberto 
Published: June 2020

Abstract

Background and Aims
Previously lacking in the literature, this analysis aims to comprehensively describe longitudinal patterns of anaemia management, including prescriptions of ESA and iron replacement, for non-dialysis dependent chronic kidney disease (NDD-CKD) stage 3 to 5 patients under nephrologist care.

Method
We analysed data from a prospective cohort of 2455 NDD-CKD patients from Brazil, Germany and the US, who were not using anaemia medications (oral iron, intravenous [IV] iron, or erythropoiesis stimulating agent [ESA]) at enrolment in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDOPPS). We excluded 26% (N=862) of patients who were using any anaemia treatment from the source population at CKDOPPS study entry; we further excluded patients with (a) missing data for demographics and/or clinical history, or (b) no laboratory and medication data during follow-up. We reported the cumulative incidence (CI) of anaemia treatment initiation, stratified by biochemical parameters and patient characteristics. For patients that started therapy, we report the frequency of medication type at the moment of initiation, as well as switches and discontinuation over 12 months.

Results
The CI of any anaemia treatment initiation at 12 months was 18% for the whole sample, and 54% for patients with haemoglobin (Hb) &lt;10 g/dL. For oral iron therapy, the CI at 12 months was 26% (19%, 32%) for TSAT&lt;20%, and 22% (17%, 28%) for ferritin &lt;100. For IV iron use, CI at 12 months was 6% (3%, 11%) for patients with TSAT&lt;20% and 4% (2%, 7%) for patients with ferritin &lt;100ng/mL. For ESA use, the CI at 12 months was 38% (29%, 47%) for patients with Hb &lt;10 g/dL, and 11% (8%, 14%) for Hb 10 to &lt;12 g/dL. Oral iron alone was the overwhelming first treatment option in the US (67%) and Brazil (56%); in Germany, a higher prevalence of ESAs (38%) and IV iron use (15%) was noted. Anaemia medication switches and discontinuation patterns, over 12 months, are outlined in the figure. The majority patients starting anaemia treatment were no longer on therapy one year later in Brazil (54%) and the US (51%); discontinuation of treatment was much lower in Germany (22%).

Conclusion
Anaemia treatment is initiated in a limited number of NDD-CKD patients with clinical signs that would indicate to do so, and many patients discontinue treatment, for reasons yet to be clarified. Although haemoglobin was the main factor associated with prescriptions, only about half of patients with Hb&lt;10g/dL received any anaemia medication during a year. Oral iron was the treatment option most often prescribed, however given to only a quarter of iron deficient patients. We noticed country differences in the patterns of anaemia prescription and treatment discontinuation, over time, that could be due to regional policy and physician-led CKD anaemia management inequalities. These results provide longitudinal data supporting the concept that anaemia is sub-optimally managed among patients with NDD CKD in the real-world setting.