A Canadian Survey of Prescribing Practices of Erythropoiesis-Stimulating Agents in Dialysis-Dependent and Non-Dialysis-Dependent Chronic Kidney Disease.

BACKGROUND

Erythropoiesis-stimulating agents (ESAs) are commonly used to manage chronic kidney disease (CKD)-associated anemia. There is a paucity of clear guidelines on their use in patients with CKD and with history of stroke or malignancy.

OBJECTIVE

To identify hemoglobin targets/thresholds, ESA prescribing practices and patterns, and prescriber comfort in patients with CKD and with history of stroke or malignancy.

STUDY DESIGN AND

SETTING

We administered an online, cross-sectional survey to nephrologists, nephrology trainees, nurse practitioners, and pharmacists affiliated with the Canadian Society of Nephrology (CSN) from March 11 to June 30, 2024.

METHODS

Survey questions were designed to determine the prescribing practices of ESAs for both general patients with CKD and those with CKD and history of stroke, active malignancy, or prior malignancy. Survey design was finalized using a 4-stage modified Delphi process. Ordinal regression was used to assess the association between baseline characteristics and prescriber comfort.

RESULTS

In all, 24% (127/540) of potential participants responded, with 121 responses included in the final survey analysis. Most respondents were nephrologists (67%, 81/121). Only 9%, 7%, and 4% of respondents reported having an institutional protocol for anemia management for patients with CKD and history of stroke, active malignancy, or previous malignancy, respectively. The most common hemoglobin target for general patients with CKD was 95 to 115 g/L. For those with history of stroke, active, or previous malignancy, it was 90 to 105 g/L. Self-reported prescriber comfort was greatest in general patients with CKD. Among all prescribers, comfort ratings were significantly lower when prescribing ESAs in those with stroke or malignancy. Nephrologists and nephrology trainees were more likely to report higher comfort ratings when prescribing ESAs in patients with CKD and active malignancy (odds ratio [OR] = 2.80, 95% confidence interval [CI] = 1.12-6.96) compared with nonphysicians.

LIMITATIONS: There was a potential for nonresponse bias given the response rate of 24%. Sampling bias may have been introduced with convenience sampling of solely kidney care providers affiliated with the CSN.

CONCLUSION

This study highlights the variability of ESA prescribing practices and anemia management across Canada in patients with CKD and with stroke or malignancy. Our findings emphasize the need for guidelines to manage ESA prescribing in these populations.