| Abstract|| |
We aimed in this study to evaluate the attitude of physicians in the Kingdom of Saudi Arabia (KSA) towards strategies for treatment of anemia in patients with chronic kidney disease (CKD). A questionnaire was sent to 153 physicians in 148 active dialysis units in the KSA including centers under the Ministry of Health (MOH) (73.6 %), centers in the governmental non-MOH sector (12.2%) and centers in private hospitals (14.2 %) that together care for a population of more than 7900 chronic dialysis patients. The study was performed between April and June 2006. A total of 137 physicians (89.5%) answered the questionnaire from 129 (87.1%) dialysis centers that catered to 7052 (89.2%) dialysis patients. There were 104 respondents (75.9%) who staged their CKD patients according to the level of glomerular filtration rate (GFR). The estimated mean prevalence of each stage of CKD in the respondents' clinics was 15%, 19%, 29%, 22%, and 29% for the stages 1,2,3,4, and 5, respectively. The estimated prevalence of anemia [hemoglobin (Hb) <110 g/L] in the different stages of CKD were 11%, 17%, 38%, 59%, and 78% in stages 1, 2, 3, 4, and 5, respectively. However, only 69 respondents (48%) answered these two questions. Sixty-seven respondents (50.4 %) believed that any patient with Hb < 110 g/L should receive r-HuEPO irrespective of the CKD stage, and 133 (99.3%) believed that correction of anemia in the CKD patients has documented impact on morbidity and mortality. In case of availability of a long acting r-HuEPO such as darbepoetin, 88 (66.2%) respondents would use it as their first choice other than the current short acting drug. Our survey suggests that the current practices concerning anemia management in CKD patients in the KSA may not be satisfactory. There are many centers that do not have data on the prevalence of CKD or anemia in their units. More studies are required to explore the quality of services rendered to the CKD patients and guidelines need to be outlined for the management of anemia in the CKD patients.
Keywords: Chronic, Kidney, Disease, Renal, Dialysis, Anemia, Darbepoetin, Stages.
|How to cite this article:|
Souqiyyeh MZ, Shaheen FA. Attitude of Physicians in Saudi Arabia towards Anemia Treatment Strategies in Patients with Chronic Kidney Disease. Saudi J Kidney Dis Transpl 2007;18:65-72
|How to cite this URL:|
Souqiyyeh MZ, Shaheen FA. Attitude of Physicians in Saudi Arabia towards Anemia Treatment Strategies in Patients with Chronic Kidney Disease. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2020 Oct 30];18:65-72. Available from: https://www.sjkdt.org/text.asp?2007/18/1/65/31848
| Introduction|| |
Surveys of opinion have been used as a tool for evaluation of current routine practices and beliefs in the nephrology community concerning certain issues related to the care of patients.,,
There has been increasing interest over the last decade towards the early care of patients with chronic kidney disease (CKD). A system of staging of the CKD patients depending on estimation and measurement of the glomerular filtration rate (GFR) has been proposed, ,,,,,, and epidemiological studies to assess the prevalence of CKD in the general population have been performed. ,
Cardiovascular morbidity and mortality in patients with CKD is related to the control of the risk factors inherent with the disease such as anemia, ,,,,, which is also a risk factor for the progression of CKD. Relation of early care of CKD patients and its impact on the outcome has been increasingly studied. ,,, Treatment of anemia has seen great improvement with the availability of recombinant human erythropoietin (r-HuEPO). Long-acting r-HuEPO is emerging as a better choice for the management of anemia in pre-dialysis CKD patients than the short-acting preparation.,
There is a need to devise a system for screening and reporting of the GFR in the general population in the Kingdom of Saudi Arabia (KSA) as well as early referral of patients with CKD to a nephrologist. The aim of this study is to survey the attitudes of the heads of kidney centers in the KSA towards treatment strategies for anemia in CKD patients.
| Materials and Methods|| |
A questionnaire was sent from the Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia to 153 physicians comprising the heads of the 148 active dialysis centers in the KSA and seven other consultants working in these units. This covered decision makers in 109 centers (73.6 %) in the Ministry of Health (MOH), 18 centers (12.2%) in the governmental, non-MOH sector and 21 centers (14.2 %) in private hospitals that care for a population of more than 7900 chronic dialysis patients. The study was performed between April and June 2006.
The questionnaire was intended to evaluate the following aspects in the practice of physicians who take care of CKD patients in the KSA:
a) The perception of the physicians towards the significance of evaluation of renal function of CKD patients in order to stage them,
b) Knowledge of the respondents about the prevalence of and their approach to treatment of anemia in CKD patients, c) Beliefs and experience on the use of rHuEPO in CKD patients.
We considered the best answers as those in accordance with the common denominator of the established guidelines and practices in the United States of America (USA) and Europe that include:
a) A recommendation to stage CKD patients based on the estimation of GFR,
b) A recommendation for aggressive approach to the evaluation and management of anemia in CKD patients,
c) A recommendation to use r-HuEPO in the management of anemia in CKD patients.
Data were entered in a Microsoft Excel file. However, the description of data and analysis were done using the statistical program SPSS. The valid percent of the answers was considered according to the frequency of the answers to each corres-ponding question.
Pearson Chi-Square test was used throughout the analysis to test the significance of differences between groups and sub-groups. Significance was set as P<0.05.
| Results|| |
A total of 137 of the 153 physicians (90.9%) answered the questionnaire from 129 (87.1%) dialysis centers that covered 7050 (89.2%) dialysis patients in the KSA. There were 113 respondents (105%) from 104 MOH centers, 11 (61%) from 18 governmental non-MOH centers and 13 (62%) from 21 private centers.
[Table - 1] shows the answers related to the evaluation of renal function in CKD patients. There were 104 respondents (75.9%) who staged their CKD patients according to the level of GFR. The GFR was calculated by the standard method by 43 respondents (35.5%), while 58 (47.9%) used 24-hour creatinine clearance for estimation of GFR. The estimated mean prevalence of each stage of CKD in the respondents' clinics was 15% for stage 1, 19% for stage 2, 29% for stage 3, 22% for stage 4, and 29% for stage 5. However, only a mean of 69 respondents (48%) answered this question. There were 123 respondents (89.8%) who believed that nephrologists should be involved in the follow-up of patients from early stages of CKD.
[Table - 2] shows the issues related to knowledge of the respondents about the prevalence of and their approach to management of anemia in CKD patients. The estimated mean prevalence of anemia [hemoglobin (Hb) <110 g/L] in the different stages of CKD according to the opinion of the respondents was 11% in stage 1, 17% in stage 2, 38% in stage 3, 59% in stage 4, and 78% in stage 5. However, only 69 respondents (48%) answered this question. There were 123 respondents (91.8%) who would evaluate their CKD patients to rule out other causes of anemia such as iron deficiency or occult bleeding before starting r-HuEPO. Furthermore, 67 respondents (50.4 %) believed that any patient with Hb<110 g/L should receive rHuEPO irrespective of the stage of CKD, and 133 (99.3%) believed that correction of anemia in the CKD patients has a documented impact on morbidity and mortality.
[Table - 3] shows the physicians' beliefs and experience on the use of r-HuEPO in CKD patients. There were 79 respondents (60.8%) who believed that the frequency of injections of r-HuEPO in CKD patients should, on average, be more than once weekly and 12 (9.2%) others believed that once monthly administration was sufficient. If long-acting r-HuEPO such as darbepoietin was available, 88 respondents (66.2%) would use it as their first choice. In the case of inadequate response to r-HuEPO, 115 (85.8%) would investigate the cause rather than merely increasing the dose of the drug. There were 104 respondents (78.2%) who would consider the efficacy, safety, and cost before deciding on which r-HuEPO preparation to prefer in practice; only 58 (43.6%) approved dispensing pre-filled injections of r-HuEPO to the CKD patients to be self-injected at home. There were 38 respondents (28.8%) who believed that antibodies to r-HuEPO were encountered more with the use of short acting r-HuEPO than darbepoetin. Finally, 102 respondents (74.5%) would choose a long acting r-HuEPO preparation for peritoneal dialysis patients.
There were no statistically significant differences among the respondents according to their affiliations (MOH, non MOH and private sector) on any of the issues in the questionnaire.
| Discussion|| |
The current study attempted to detect the attitude of the physicians in charge of the kidney centers in the KSA towards the management of anemia in pre-dialysis CKD patients in their respective centers.
Our results revealed that the majority of the respondents stage their patients according to the GFR level, although there is no consensus on the best method of measurement of GFR.
Some preferred the calculated GFR from formulae, while others depended on the 24hour collection of urine to calculate the GFR, and a third group would use both approaches. Similar lack of consensus exists in the literature about the best method of estimation of GFR, since there is over- or underestimation inherent with these methods.  However, some work groups advocate the use of these methods to screen the general population or in certain high-risk subgroups such as diabetics. , The majority of the participants in our study did not give an estimate of the prevalence of the different stages of CKD in their practices. This could be due to the non-availability of statistics. However, attention to the pre-dialysis population is very important since more than 10% of the general population can be labeled as CKD patients.  Furthermore, an additional 10% of the general population (hypertensive and diabetics) is at risk of developing CKD.  Therefore, staging of CKD patients may help in proper health planning and adopting preventive strategies for combating CKD. Our respondents believed that nephrologists should be involved in the follow-up of the CKD patients at early stages of the disease. Similar trends are found elsewhere. ,
The estimation of the respondents of the prevalence of anemia in the different stages of CKD was compatible with what is known from previous studies. , Anemia prevails more with the progression of the disease. Moreover, careful evaluation and management of anemia is rewarded usually by less morbidity and mortality.  The majority of our respondents believe in these two observations.
The convenience of the application of rHuEPO, the main stay of management of anemia in CKD patients, depends on the halflife of the preparation. The long-acting rHuEPO, darbepoetin, has gained popularity in recent years in the treatment of anemia in the CKD patients due to the long interval required between the doses (almost one month). ,,,,, The majority of our respondents concurred with this benefit of darbepoetin in CKD patients. Many of the respondents were dissatisfied with administering the r-HuEPO at home, which makes the use of long-acting preparations such as darbepoetin even more convenient.
Generally, the vast majority of nephrologists judge r-HuEPO according to the efficacy, safety and cost., Darbepoetin has been judged by previous studies as a safe and cost effective drug. ,,
Our survey suggests that that the current practices concerning management of anemia in CKD patients in the KSA may not be satisfactory. There are many centers that do not have data on the prevalence of CKD or anemia in their units. More studies are required to explore the quality of services rendered to CKD patients and guidelines need to be outlined for the management of anemia in CKD patients.
| Acknowledgement|| |
We would like to thank Amgen Pharmaceuticals in Saudi Arabia for their grant that made this study possible.
| References|| |
|1.||Powe NR, Thamer M, Hwang W, et al. Cost-quality trade-offs in dialysis care: a national survey of dialysis facility administrators. Am J Kidney Dis 2002;39(1):116-26. |
|2.||Zimmerman DL, Selick A, Singh R, Mendelssohn DC. Attitudes of Canadian nephrologists, family physicians and patients with kidney failure toward primary care delivery for chronic dialysis patients. Nephrol Dial Transplant 2003;18(2):305-9. |
|3.||Van Waeleghem JP, Elseviers MM, De Weerdt DL, et al. A survey of nephrology nursing care and treatments in Belgium. Nephrol News Issue 1998;12(11):53-6. |
|4.||Macgregor MS, Boag DE, Innes A. Chronic kidney disease: evolving strategies for detection and management of impaired renal function. QJM 2006; 99(6):365-75. |
|5.||Van Biesen W, Vanholder R, Veys N, et al. The importance of standardization of creatinine in the implementation of guidelines and recommendations for CKD: implications for CKD management programmes. Nephrol Dial Transplant 2006; 21(1):77-83. |
|6.||Levin A, Stevens LA. Executing change in the management of chronic kidney disease: perspectives on guidelines and practice. Med Clin North Am 2005; 89(3):701-9. |
|7.||Levey AS, Eckardt KU, Tsukamoto Y, et al. Definition and classification of chronic kidney disease: a position statement from Kidney Disease. Improving Global Outcomes (KDIGO). Kidney Int 2005;67(6):2089-100. |
|8.||Snyder S, Pendergraph B. Detection and evaluation of chronic kidney disease. Am Fam Physician 2005;72(9):1723-32. |
|9.||Anavekar N, Bais R, Carney S, et al. The Australian Creatinine Consensus Working Group. Chronic kidney disease and automatic reporting of estimated glomerular filtration rate: a position statement. Clin Biochem Rev 2005; 26(3):81-6. |
|10.||de Jong PE, Gansevoort RT. Screening techniques for detecting chronic kidney disease. Curr Opin Nephrol Hypertens 2005;14(6):567-72. |
|11.||Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey. Am J Kidney Dis 2003; 41(1):1-12. |
|12.||Jurkovitz C, Abramson J, McClellan WM. Anemia and cardiovascular and kidney disease. Curr Opin Nephrol Hypertens 2006; 15(2):117-22. |
|13.||Locatelli F, Pozzoni P, Del Vecchio L. Anemia and heart failure in chronic kidney disease. Semin Nephrol 2005;25(6):392-6. |
|14.||Foley RN, Murray AM, Li S, et al. Chronic kidney disease and the risk for cardiovascular disease, renal replacement, and death in the United States Medicare population, 1998 to 1999. J Am Soc Nephrol 2005 ;16(2):489-95. |
|15.||Besarab A, Soman S. Anemia management in chronic heart failure: lessons learnt from chronic kidney disease. Kidney Blood Press Res 2005;28(5-6):363-71. |
|16.||Locatelli F, Pisoni RL, Combe C, et al. Anaemia in hemodialysis patients of five European countries: association with morbidity and mortality in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant 2004; 19(1):121-32. |
|17.||Stevens LA, Levin A. Anaemia, cardiovascular disease and kidney disease: integrating new knowledge in 2002. Curr Opin Nephrol Hypertens 2003;12(2):133-8. |
|18.||Deicher R, Horl WH. Anaemia as a risk factor for the progression of chronic kidney disease. Curr Opin Nephrol Hypertens 2003; 12(2):139-43. |
|19.||Obrador GT, Pereira BJ. Early referral to the nephrologist and timely initiation of renal replacement therapy: a paradigm shift in the management of patients with chronic renal failure. Am J Kidney Dis 1998;31(3):398-417. |
|20.||Levin A. Consequences of late referral on patient outcomes. Nephrol Dial Transplant 2000;15 Suppl 3:8-13. [PUBMED] [FULLTEXT]|
|21.||Roderick P, Jones C, Tomson C, Mason J. Late referral for dialysis: improving the management of chronic renal disease. QJM 2002;95(6):363-70. |
|22.||St Peter WL, Schoolwerth AC, McGowan T, McClellan WM. Chronic kidney disease: issues and establishing programs and clinics for improved patient outcomes. Am J Kidney Dis 2003;41(5):903-24. |
|23.||Locatelli F, Canaud B, Giacardy F, Martin-Malo A, Baker N, Wilson J. Treatment of anaemia in dialysis patients with unit dosing of darbepoetin alfa at a reduced dose frequency relative to recombinant human erythropoietin (rHuEpo). Nephrol Dial Transplant 2003; 18(2):362-9. |
|24.||Martinez Castelao A, Reyes A, Valdes F, et al. Multicenter study of darbepoetin alfa in the treatment of anemia secondary to chronic renal insufficiency on dialysis. Nefrologia 2003; 23(2):114-24. |
|25.||Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 2003; 139(2):137-47. |
|26.||European Best Practice Guidelines Group. Measurement of renal function, when to refer and when to start dialysis. Nephrol Dial Transplant 2002; 17 Suppl (7):7-15. |
|27.||Lamb EJ, Tomson CR, Roderick PJ. Clinical Sciences Reviews Committee of the Association for Clinical Biochemistry. Estimating kidney function in adults using formulae. Ann Clin Biochem 2005;42(Pt 5):321-45. |
|28.||Mathew TH, Australian Creatinine Consensus Working Group.Chronic kidney disease and automatic reporting of estimated glomerular filtration rate: a position statement.Med J Aust 2005 ;183(3):138-41. |
|29.||Rigalleau V, Lasseur C, Perlemoine C, et al. Estimation of glomerular filtration rate in diabetic subjects: Cockcroft formula or modification of Diet in Renal Disease study equation? Diabetes Care 2005;28(4):838-43. |
|30.||Stevens P. Optimizing renal anaemia management-benefits of early referral and treatment. Nephrol Dial Transplant 2005;20 Suppl 8:viii22-6. [PUBMED] [FULLTEXT]|
|31.||Dean BB, Dylan M, Gano A Jr, Knight K, Ofman JJ, Levine BS. Erythropoiesisstimulating protein therapy and the decline of renal function: a retrospective analysis of patients with chronic kidney disease. Curr Med Res Opin 2005; 21(7):981-7. |
|32.||Jungers PY, Nguyen-Khoa T, Joly D, Choukroun G, Massy ZA, Jungers P. Frequency of anaemia and indications for treatment with epoetin in chronic renal failure at the pre-dialysis stage. Presse Med 2003;32(5):212-6. |
|33.||Obrador GT, Pereira BJ.Anaemia of chronic kidney disease: an underrecognized and under-treated problem. Nephrol Dial Transplant 2002;17 Suppl 11:44-6. [PUBMED] [FULLTEXT]|
|34.||Foley RN. Anaemia: cardiovascular adaptations and maladaptive responses in chronic kidney disease. Nephrol Dial Transplant 2002;17 Suppl 11:32-4. [PUBMED] [FULLTEXT]|
|35.||Provenzano R, Bhaduri S, Singh AK, PROMPT Study Group. Extended epoetin alfa dosing as maintenance treatment for the anemia of chronic kidney disease: the PROMPT study. Clin Nephrol 2005;64(2):113-23. |
|36.||Locatelli F. Once weekly treatment with epoetin-beta. Nephrol Dial Transplant 2005;20 Suppl 6:vi26-30. [PUBMED] [FULLTEXT]|
|37.||Barre P, Reichel H, Suranyi MG, Barth C. Efficacy of once-weekly epoetin alfa. Clin Nephrol 2004;62(6):440-8. |
|38.||Locatelli F, Canaud B, Giacardy F, Martin-Malo A, Baker N, Wilson J. Treatment of anaemia in dialysis patients with unit dosing of darbepoetin alfa at a reduced dose frequency relative to recombinant human erythropoietin (rHuEpo). Nephrol Dial Transplant 2003; 18(2):362-9. |
|39.||Martinez Castelao A, Reyes A, Valdes F, et al. Multicenter study of darbepoetin alfa in the treatment of anemia secondary to chronic renal insufficiency on dialysis. Nefrologia 2003; 23(2):114-24. |
|40.||Scott SD. Dose conversion from recombinant human erythropoietin to darbepoetin alfa: recommendations from clinical studies. Pharmacotherapy 2002; 22(9 Pt 2):160S-5S. |
|41.||Deray G.Achieving therapeutic targets in renal anaemia: considering costefficacy.Curr Med Res Opin 2004;20(7):1095-101. |
|42.||London R, Solis A, Goldberg GA, Wade S, Ryu S. Health care resource utilization and the impact of anemia management in patients with chronic kidney disease. Am J Kidney Dis 2002; 40(3):539-48. |
|43.||Glaspy J. Phase III clinical trials with darbepoetin: implications for clinicians. Best Pract Res Clin Haematol 2005; 18(3):407-16. |
|44.||Verhelst D, Rossert J, Casadevall N, Kruger A, Eckardt KU, Macdougall IC. Treatment of erythropoietin-induced pure red cell aplasia: a retrospective study. Lancet 2004; 363(9423):1768-71. |
|45.||Theodoridis M, Passadakis P, Kriki P, et al. Efficient monthly subcutaneous administration of darbepoetin in stable CAPD patients. Perit Dial Int 2005; 25(6):547-50. |
Muhammad Ziad Souqiyyeh
Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh, 11417
[Table - 1], [Table - 2], [Table - 3]