title: Initiation of anaemia management in patients with chronic kidney disease not on dialysis in the Veterans Health Administration.
abstract: BACKGROUND
  Erythropoiesis-stimulating agents (ESAs) are frequently used to treat anaemia of chronic kidney disease (CKD) in the dialysis setting; however, few data are available regarding factors influencing initiation of ESAs and other therapies in non-dialysis patients.
  
  
  METHODS
  A retrospective cohort study of Veterans Health Administration data from 2003 to 2005 for 89 585 patients identified as having CKD and anaemia based on two outpatient estimated glomerular filtration rates <60 ml/min/1.73 m(2) and at least one outpatient haemoglobin (Hb) <11 g/dL. Hb levels, patient demographics, clinical and provider characteristics and procedures predicted ESA treatment initiation over 1 year of follow-up. Multivariable logistic and pooled logistic survival models identified predictors of ESA initiation.
  
  
  RESULTS
  Overall, 6381 subjects (7.1%) initiated ESAs within 1 year of the index Hb; initiation was more common (8.6%) for patients with Hb <10 g/dL. Iron therapy use varied by initial Hb levels (27.6% to 52.4%) as did transfusions (12.5% to 42.8%); each was more common at lower Hb levels. Hbs rose to above 11 g/dL for 25-50% of patients in the absence of any treatment or by transfusion/iron therapy. Factors predicting time to ESA initiation included: nephrologist [odds ratio (OR = 2.3)] or haematologist care (OR = 2.2) and iron therapy (OR = 1.6). Transfusions increased for patients with increasing follow-up time.
  
  
  CONCLUSIONS
  Iron therapy is more common than ESA treatment in patients with CKD and Hbs <11 g/dL in the VA. Correction of anaemia in the absence of any ESA treatment was common at higher Hbs levels, but much less so when Hb levels fell below 10 g/dL.
authors.affiliation: Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Cooperative Studies Program, VA Boston Healthcare System, Boston, MA, USA. Elizabeth.Lawler@med.va.gov
authors.forename: Elizabeth V
authors.initials: EV
authors.lastname: Lawler
authors.forename: David R
authors.initials: DR
authors.lastname: Gagnon
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Fink
authors.forename: Stephen
authors.initials: S
authors.lastname: Seliger
authors.forename: Jennifer
authors.initials: J
authors.lastname: Fonda
authors.forename: Thy P
authors.initials: TP
authors.lastname: Do
authors.forename: J Michael
authors.initials: JM
authors.lastname: Gaziano
authors.forename: Brian D
authors.initials: BD
authors.lastname: Bradbury
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000740:Anemia / Q000097:blood / Q000188:drug therapy*; D002908:Chronic Disease; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D005919:Glomerular Filtration Rate / Q000502:physiology; D006397:Hematinics / Q000627:therapeutic use*; D006454:Hemoglobins / Q000378:metabolism; D006801:Humans; D007674:Kidney Diseases / Q000150:complications* / Q000503:physiopathology; D008297:Male; D006435:Renal Dialysis; D012189:Retrospective Studies; D014481:United States; D014493:United States Department of Veterans Affairs
chemical_list: D006397:Hematinics; D006454:Hemoglobins