Nephron 2018;139(suppl1): DOI: /

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1 Nephron 18;139(suppl1):165 1 DOI: /4965 Published online: July 11, 18 UK Renal Registry th Annual Report: Chapter 7 Haemoglobin, Ferritin and Erythropoietin in UK Adult Dialysis Patients in 16: National and -specific Analyses Rhodri Pyart a, Julie Gilg a, Andrew J Williams b a UK Renal Registry, Bristol, UK; b Morriston Hospital, Swansea, UK Keywords Anaemia. Chronic kidney disease. Dialysis. End stage renal disease. Epidemiology. Erythropoietin. Erythropoiesis stimulating agent. European Best Practice Guidelines. Ferritin. Haemodialysis. Haemoglobin. NICE. Peritoneal dialysis. Renal Association Summary In the UK in 16:. The median haemoglobin (Hb) of at the time of starting dialysis was 99 g/l with 47% of having a Hb 5 g/l.. The median Hb in starting haemodialysis (HD) was 96 g/l (IQR 87 15) and in starting peritoneal dialysis (PD) was 18 g/l (IQR ).. At the start of dialysis, % of presenting early had Hb 5 g/l compared with only 34% of presenting late.. The median Hb of prevalent on HD was 111 g/l (IQR ).. The median Hb of prevalent on PD was 111 g/l (IQR 12 1).. % of prevalent HD and 79% of PD had Hb 5 g/l.. 59% of prevalent HD and 55% of PD had Hb 5 and 41 g/l.. The median serum ferritin in HD was 41 mg/l and 94% of HD had a ferritin 5 mg/l.. The median serum ferritin in PD was 6 mg/l and 88% of PD had a ferritin 5 mg/l. In England, Wales and Northern Ireland in 16:. The median erythropoiesis stimulating agent (ESA) dose in HD was 7,7 IU/week.. The median ESA dose in PD was 4, IU/ week. Fax karger@karger.com # 18 The UK Renal Registry Published by S. Karger AG, Basel This article is licensed under the Creative Commons Attribution- NonCommercial-NoDerivatives 4. International License (CC BY- NC-ND) ( Usage and distribution for commercial purposes as well as any distribution of modified material requires written permission. Rhodri Pyart UK Renal Registry, Southmead Hospital, Southmead Road, Bristol, BS1 5NB, UK renalregistry@renalregistry.nhs.uk

2 Introduction Anaemia is a common complication of chronic kidney disease (CKD). It is associated with morbidity and mortality as well as reduced exercise tolerance and quality of life. Iron therapies and erythropoiesis stimulating agents (ESAs) remain the mainstay of the management of with renal anaemia, minimising the need for blood transfusions. This chapter describes analyses of the management of anaemia in dialysis in the UK in 16. The attainment of parameters is compared at a renal centre and national level as well as against national performance measures as set out in the Renal Association (RA) practice guidelines which are published online. The audit measures applied to the care of dialysis in 16 and recommended in this chapter are taken from the Renal Association Clinical Practice Guideline for Anaemia of CKD (5th edition) published online in 1 [1]. Table 7.1 lists the audit measures recommended in these guidelines alongside those parameters measured in this chapter and where applicable reasons for exclusion. In mid-17, an updated 6th edition of the Renal Association guideline was published [2] which endorses the National Institute for Health and Care Excellence (NICE) guideline for anaemia management in chronic kidney disease 15 [3]. The recommended haemoglobin targets remain the same although the indices for assessing patient iron status have changed. Specifically, percentage hypochromic red blood cells (HRC) or reticulocyte haemoglobin content (CHr) are recommended as preferable markers of iron deficiency to serum ferritin or transferrin saturation. The impact this will have on both clinical Table 7.1. Summary of recommended Renal Association audit measures RA audit measure 1. Proportion of CKD with egfr, ml/min by 4 variable MDRD method with an annual Hb level 2. Proportion of starting an ESA without prior measurement of serum ferritin and/or TSAT 3. Proportion of on renal replacement therapy with Hb level,1 who are not prescribed an ESA 4. Each renal unit should audit the type, route and frequency of administration and weekly dose of ESA prescribed Included in UKRR annual report? No No Yes Partly Reason for exclusion Data not available for the period covered by this report UKRR does not know when all start ESA treatment. UKRR does not collect TSAT data UKRR reports the completeness of these data items 5. The proportion of CKD stage 4 5 with Hb 1 12 g/dl No Data not available for the period covered by this report 6. The proportion of treated with an ESA with Hb.12 g/dl Yes 7. Each renal unit should monitor ESA dose adjustments No UKRR does not collect this data 8. Proportion of with serum ferritin levels, ng/ml at start of treatment with ESA 9. Proportion of pre-dialysis and PD receiving iron therapy; type: oral vs parenteral No No UKRR does not know when all start ESA treatment Data not available for the period covered by this report/poor data completeness 1. Proportion of HD receiving IV iron No Poor data completeness 11. Prevalence of resistance to ESA among renal replacement therapy 12. Proportion of HD who received a blood transfusion within the past year Yes No Data held at NHS Blood and Transplant 166 Nephron 18;139(suppl1):165 1 Pyart/Gilg/Williams

3 practice and centre reporting through the UKRR remains to be seen. The guidelines acknowledge the practical challenges of measuring HRC due to the need for timely testing on specialist analysers. CHr does not currently form part of the UKRR renal dataset and further work will be undertaken by the UKRR in collaboration with renal centres to explore the ability to report this variable. Internationally, The Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Anemia in Chronic Kidney Disease was published in August 12 [4] and is yet to be updated. Methods Most of the analyses in this chapter use the incident or prevalent renal replacement therapy (RRT) cohorts for 16. Some analyses use data from earlier years. Haemoglobin levels are given in g/l as the majority of UK laboratories have now switched to reporting using these units rather than g/dl. The UKRR extracted quarterly data electronically from renal centres in England, Wales and Northern Ireland (E,W & NI) taking the latest available result from each quarter. Data from Scotland were provided by the Scottish Renal Registry (SRR). For the analyses of Hb for incident, those commencing RRT on PD or HD were included whilst those receiving a pre-emptive transplant were excluded. Hb measurements from after starting dialysis but still within the same quarter of the year were used. Therefore, depending on when in the quarter a patient started RRT the Hb data could be from zero to days later. Due to possible deficiencies with extract routines it is possible that a small number of the values extracted electronically may actually be from before the person started dialysis. This problem will not occur for Scottish data. Patients who died within the first days on treatment were excluded. Results are also shown with the cohort subdivided into early and late presenters (date first seen by a nephrologist, or more days and less than days before starting dialysis respectively). For these analyses only centres with at least 75% completeness of presentation time data were included. For the analyses of prevalent dialysis those receiving dialysis on 31 December 16 were included if they had been on the same modality of dialysis in the same centre for at least three months. In order to improve completeness, the last available measurement for each patient from the last two quarters was used for Hb and from the last three quarters for ferritin. The completeness of data items were analysed at both centre and country level. All were included in analyses but centres with less than % completeness were excluded from the caterpillar and funnel plots showing centre level results. s providing relevant data from less than ten were also excluded from the plots. The number preceding the centre name in the caterpillar plots is the percentage of who have data missing. Summary statistics including minimum, maximum, interquartile ranges (IQR), averages (mean and median) and standard deviations were calculated. The median values and the IQRs are shown using caterpillar plots. The percentages achieving standards were also calculated and these are displayed using caterpillar plots with the percentages meeting the targets and 95% confidence intervals (CIs) shown. Funnel plots show the distribution of the percentages meeting the targets and also whether any of the centres were significantly different from the average. Longitudinal analyses were performed to show overall changes in achievement of standards over time. Erythropoietin data from the last quarter of 16 were used to define which were receiving erythropoietin stimulating agents (ESAs). Scotland was excluded from this analysis due to incomplete data. Each individual was defined as being on ESA if a drug type and/or a dose was present in the data. s reporting fewer than % of HD or fewer than % of PD being treated with ESAs were considered to have incomplete data and were excluded from further analysis. It is recognised that these exclusion criteria are relatively arbitrary but they are in part based upon the frequency distribution graph of centres ESA use as it appears in the data. The percentage of on ESAs was calculated from these data and incomplete data returns risk seriously impacting on any conclusions drawn. For analyses of ESA dose, values are presented as weekly erythropoietin dose. Doses of less than 1 IU/week (assumed to be darbepoietin or methoxy polyethylene glycol epoetin beta) were harmonised with erythropoietin data by calculating a weekly dose and multiplying by. No adjustments were made with respect to route of administration. Patients who were not receiving ESAs were not included in analyses of dose (rather than being included with dose = ). Many centres provided data on ESA dose but not on ESA frequency. The ESA dose field is defined as the weekly dose and the dose is presumed to have been converted accordingly on submission to the UKRR. This may be an incorrect assumption for a number of and this needs to be considered when interpreting the ESA information. Starting with the cohort of receiving ESAs in the final quarter of the year and having a dose value present for that quarter, any further dose values available from the earlier three quarters of the year were used (provided the patient was on the same treatment and receiving the same drug in those quarters). The average (mean) of the available values was then used in analyses rather than the dose in the final quarter. The ESA data were collected electronically from renal IT systems but in contrast to laboratory linked variables the ESA data required manual data entry. The reliability depended upon the data source, whether the entry was linked to the prescription or whether the prescriptions were provided by the primary care physician. In the latter case, doses may not be as reliably updated as the link between data entry and prescription was indirect. The three centres in North Wales, namely Wrexham, Bangor and Clwyd used several databases including their renal IT system for ESA data in HD and were therefore excluded from the HD ESA analysis. Cambridge renal centre (Addenbrooke s) was unable to submit their 16 (and 15) data at patient level prior to the UKRR closing the database and only provided summary numbers of starting RRT by treatment modality. This centre is therefore excluded from most analyses in this chapter. The data were analysed using SAS 9.3. Anaemia management in UK dialysis Nephron 18;139(suppl1):

4 Table 7.2. Haemoglobin data for incident starting RRT on haemodialysis or peritoneal dialysis during 16, both overall and by presentation time % data return All incident dialysis Early presenters (5 days) Late presenters (, days) N with data Hb g/l 5 g/l Hb g/l 5 g/l Hb g/l 5 g/l England B Heart B QEH Basldn Bradfd Brightn Bristol Camb n/a n/a Carlis Carsh Chelms Colchr Covnt Derby Donc Dorset Dudley Exeter Glouc Hull Ipswi Kent L Barts L Guys L Kings L Rfree L St.G L West 89 6 Leeds Leic Liv Ain Liv Roy M RI Middlbr Newc Norwch Nottm Oxford Plymth Ports Prestn Redng Salford Sheff Shrew Stevng Sthend Stoke Sund Truro Wirral Wolve York Nephron 18;139(suppl1):165 1 Pyart/Gilg/Williams

5 Table 7.2. Continued All incident dialysis Early presenters (5 days) Late presenters (, days) % data return N with data Hb g/l 5 g/l Hb g/l 5 g/l Hb g/l 5 g/l N Ireland Antrim Belfast Newry Ulster West NI Scotland Abrdn Airdrie D&Gall 64 7 Dundee Edinb Glasgw Inverns 31 5 Klmarnk Krkcldy Wales Bangor Cardff Clwyd Swanse Wrexm England 97 5, N Ireland Scotland Wales UK 95 6, n/a not available Blank cells centres excluded from the analysis due to poor data completeness or low patient numbers Results Anaemia management in incident dialysis Haemoglobin in incident dialysis As the UKRR does not collect comprehensive data on who are not yet receiving RRT, Hb at the time of starting RRT is the only indication of concordance with anaemia clinical practice guidelines in the pre-dialysis (CKD not (yet) on dialysis) group. The percentage data returned and outcome Hb are listed in table 7.2. The median Hb of at the time of starting dialysis in the UK in 16 was 99 g/l. The median Hb for at the time of starting dialysis by renal centre is shown in figure 7.1. The percentage of starting dialysis with Hb 5 g/l is shown in figure 7.2. Using data from centres with adequate completeness for date of first presentation the difference in median Hb between early ( g/l) and late (92 g/l) presenters is shown in table 7.2. These figures are unchanged from the analysis of 15 incident. Of the early presenters, % had a Hb 5 g/l compared with 34% of late presenters. Again, there was a substantial difference between Hb at the time of starting dialysis by modality. Patients starting on HD had a median Hb of 96 g/l (IQR 87 15) whilst those starting on PD had a median Hb of 18 g/l (IQR ). Of HD, % started dialysis with a Hb 5 g/l compared with 72% of PD. Incident dialysis from 15 were followed for one year and the median haemoglobin and percentage with 5 g/l in survivors on the same treatment at the same centre were calculated for each quarter. Only with Hb data for each of the four time points were included in this analysis. Results by modality and length of pre-dialysis care are shown in figures 7.3 and 7.4. The PD-late group consisted of only 38, so care should be taken in interpreting the results. Anaemia management in UK dialysis Nephron 18;139(suppl1):

6 1 11 N = 6,243 Upper quartile Hb Lower quartile Haemoglobin g/l 35 Edinb Shrew Sthend Bangor West NI 1 Derby Bristol Truro Exeter 3 Stoke 1 Belfast Ulster Ports 2 Wrexm 7 Wolve Liv Roy 2 Chelms 24 Dundee 3 Wirral Brightn 2 Plymth Carlis 2 Glouc Carsh 2 Dorset 11 L West 32 Klmarnk 5 Newry Redng 1 Prestn 1 Cardff 2 B QEH 12 Bradfd 1 Sund 2 Salford 23 L St.G Kent 25 Glasgw 1 Abrdn 13 Hull 2 L Rfree 1 Stevng 4 L Kings Sheff 2 Covnt 1 Oxford 3 Donc 4 Liv Ain 25 Krkcldy 5 Antrim 1 Middlbr Leic B Heart L Barts Swanse 1 Newc 6 York Basldn 46 Colchr 3 Ipswi 1 M RI Clwyd Norwch 2 Dudley 1 Leeds 4 Nottm Airdrie 1 L Guys 3 England 2 N Ireland 29 Scotland 1 Wales 5 UK Fig haemoglobin for incident dialysis at start of dialysis treatment in 16 N = 6,243 Upper 95% Cl % with Hb > g/l Lower 95% Cl 1 Bangor 35 Edinb Exeter Bristol West NI Ulster Shrew Sthend 1 Belfast Ports 3 Stoke 1 Derby Liv Roy 3 Wirral 24 Dundee Truro 2 Plymth 7 Wolve Carlis 2 Dorset 2 Glouc 2 Chelms 2 Wrexm Brightn Carsh 11 L West 32 Klmarnk 1 Cardff 1 Sund 1 Prestn 2 Salford 12 Bradfd 2 B QEH 5 Newry 4 Liv Ain 23 L St.G Redng 4 L Kings 25 Krkcldy 3 Donc 2 L Rfree Kent 1 Oxford 25 Glasgw 13 Hull 1 Middlbr 1 Stevng Sheff 6 York 2 Covnt 1 Abrdn B Heart 4 Nottm 1 M RI 46 Colchr 3 Ipswi Swanse Leic 5 Antrim 2 Dudley L Barts Norwch 1 Newc Airdrie 1 Leeds Basldn 1 L Guys Clwyd 3 England 2 N Ireland 29 Scotland 1 Wales 5 UK Fig Percentage of incident dialysis with Hb 5 g/l at start of dialysis treatment in 16 1 Haemoglobin g/l PD early PD late HD early HD late Percentage of incident PD early PD late HD early HD late Start 3 months 6 months 12 months Time since commencing dialysis Fig haemoglobin, by time on dialysis and length of pre-rrt care, for incident dialysis in 15 Start 3 months 6 months 12 months Time since commencing dialysis Fig Percentage of incident dialysis in 15 with Hb 5 g/l by time on dialysis and by length of pre-rrt care 1 Nephron 18;139(suppl1):165 1 Pyart/Gilg/Williams

7 Percentage of incident 1 < >1(Hb, g/l) Year of start Fig Distribution of haemoglobin in incident dialysis by year of start The distribution of Hb ranges in incident dialysis by year of start is shown in figure 7.5. The proportion of incident dialysis with Hb 51 g/l has fallen from 16.2% in 7 to 8.4% in 16. In contrast, the proportion of starting dialysis with Hb, g/l has increased from 42.9% in 7 to 52.8% in 16. The proportion of receiving an ESA by length of time on dialysis for starting dialysis in 15 is shown in figure 7.6. The difference in ESA use between early and late starters was reduced substantially after six Percentage on ESA HD early PD late HD late PD early Start 3 months 6 months 12 months Time since commencing dialysis Fig Percentage of incident dialysis in 15 on ESA, by time on dialysis and by length of pre-rrt care months of treatment. Only presenting late to dialysis and starting on PD had ESA data, so care should be taken in interpreting this result. Anaemia management in prevalent dialysis Compliance with data returns for Hb and serum ferritin are shown in table 7.3. Data completeness was generally good for Hb and ferritin. Salford did not submit any ferritin data. Percentages of reportedly receiving ESAs are shown in table 7.3. These are as received by the UKRR. Summary statistics for haemoglobin, serum ferritin and ESA are shown in table 7.4 for HD and 7.5 for PD. Table 7.3. Percentage completeness of data returns for haemoglobin and serum ferritin and percentages on ESA for prevalent HD and PD in 16 HD PD N Hb Ferritin % on ESA N Hb Ferritin % on ESA England B Heart B QEH Basldn Bradfd Brightn Bristol Carlis Carsh Chelms Colchr Covnt Derby Donc Dorset Dudley Anaemia management in UK dialysis Nephron 18;139(suppl1):

8 Table 7.3. Continued HD PD N Hb Ferritin % on ESA N Hb Ferritin % on ESA Exeter Glouc Hull Ipswi Kent L Barts L Guys L Kings L Rfree L St.G L West 1, Leeds Leic Liv Ain Liv Roy M RI Middlbr Newc Norwch Nottm Oxford Plymth Ports Prestn Redng Salford Sheff Shrew Stevng Sthend Stoke Sund Truro Wirral Wolve York N Ireland Antrim Belfast Newry Ulster West NI Scotland Abrdn Airdrie D&Gall 47 1 Dundee Edinb Glasgw Inverns Klmarnk Krkcldy Nephron 18;139(suppl1):165 1 Pyart/Gilg/Williams

9 Table 7.3. Continued HD PD N Hb Ferritin % on ESA N Hb Ferritin % on ESA Wales Bangor Cardff Clwyd Swanse Wrexm England 19, , N Ireland Scotland 1, Wales 1, UK 22, , Blank cells centres with no PD or because data were not available These three centres in North Wales did not only hold HD ESA data on their renal IT systems so have not been included in the analysis of ESA. Percentages of receiving ESA are shown but centres with less than % HD or % PD on ESA have been excluded from further analysis. Therefore, country averages are not shown these can be found in tables 7.4 and 7.5 Table 7.4. Summary statistics for haemoglobin, serum ferritin and ESA for prevalent HD in 16 N with Hb data Hb g/l 5 g/l 1 g/l ferritin mg/l % ferritin 5 mg/l % ferritin. and mg/l %on ESA ESA dose (IU/week) % with Hb 5 g/l and not on ESA England B Heart , 15 B QEH , 6 Basldn , 5 Bradfd , 4 Brightn , 1 Bristol , 7 Carlis , 24 Carsh Chelms , 6 Colchr Covnt , 15 Derby Donc ,667 8 Dorset ,375 8 Dudley Exeter , 8 Glouc Hull Ipswi Kent , 6 L Barts L Guys L Kings ,2 8 L Rfree L St.G L West 1, Leeds , 6 Leic , 2 Liv Ain Anaemia management in UK dialysis Nephron 18;139(suppl1):

10 Table 7.4. Continued N with Hb data Hb g/l 5 g/l 1 g/l ferritin mg/l % ferritin 5 mg/l % ferritin. and mg/l %on ESA ESA dose (IU/week) % with Hb 5 g/l and not on ESA Liv Roy M RI Middlbr , 25 Newc ,2 18 Norwch ,625 6 Nottm , 11 Oxford , 8 Plymth Ports Prestn Redng ,39 9 Salford Sheff , 8 Shrew Stevng , 5 Sthend , 5 Stoke Sund ,9 9 Truro Wirral , 13 Wolve , 15 York , 12 N Ireland Antrim , 8 Belfast ,7 5 Newry ,375 1 Ulster ,2 7 West NI , 7 Scotland Abrdn Airdrie D&Gall Dundee Edinb Glasgw Inverns Klmarnk Krkcldy Wales Bangor Cardff Clwyd Swanse , 1 Wrexm England 19, ,7 9 N Ireland , 7 Scotland 1, Wales 1, , 1 UK 22, ,7 9 Blank cells centres excluded from analyses due to poor data completeness or low patient numbers or because the data item was not available ESA data only shown for those centres where the percentage on ESA was % or more ESA summary results are for E, W & NI (not UK) 174 Nephron 18;139(suppl1):165 1 Pyart/Gilg/Williams

11 Table 7.5. Summary statistics for haemoglobin, serum ferritin and ESA for prevalent PD in 16 N with Hb data Hb g/l 5 g/l 1 g/l ferritin mg/l % ferritin 5 mg/l % ferritin. and mg/l %on ESA ESA dose (IU/week) % with Hb 5 g/l and not on ESA England B Heart , 22 B QEH , Basldn ,7 13 Bradfd , 5 Brightn Bristol , Carlis ,2 35 Carsh Chelms , 38 Colchr n/a Covnt , 28 Derby Donc , Dorset , Dudley Exeter , Glouc Hull , 31 Ipswi Kent , L Barts L Guys L Kings , 21 L Rfree L St.G L West Leeds , 25 Leic , 22 Liv Ain Liv Roy M RI Middlbr , 45 Newc Norwch ,483 Nottm ,5 18 Oxford ,7 21 Plymth Ports Prestn Redng Salford , 25 Sheff , 34 Shrew Stevng Sthend , Stoke Sund ,7 41 Truro Wirral , 13 Wolve , York , Anaemia management in UK dialysis Nephron 18;139(suppl1):

12 Table 7.5. Continued N with Hb data Hb g/l 5 g/l 1 g/l ferritin mg/l % ferritin 5 mg/l % ferritin. and mg/l %on ESA ESA dose (IU/week) % with Hb 5 g/l and not on ESA N Ireland Antrim , Belfast , 14 Newry , 32 Ulster 5 West NI 9 Scotland 57 Abrdn Airdrie D&Gall Dundee Edinb Glasgw Inverns 4 Klmarnk Krkcldy Wales Bangor Cardff Clwyd Swanse , 38 Wrexm England 2, ,8 27 N Ireland , Scotland Wales , 39 UK 3, , 28 Blank cells centres excluded from analyses due to poor data completeness or low patient numbers or because the data item was not available n/a not applicable ESA data only shown for those centres where the percentage on ESA was % or more ESA summary results are for E, W & NI (not UK) Haemoglobin in prevalent haemodialysis The median Hb of on HD in the UK in 16 was 111 g/l (IQR ) and is shown in table 7.4. For HD, % had a Hb 5 g/l. Figure 7.7 shows the median Hb in HD by renal centre. Figure 7.8 shows the proportion of by centre with Hb within the Renal Association guideline range ( 1 g/l) and figure 7.9 shows the distribution of Hb within, above and below this range. Funnel plots for the percentage of with Hb 5 g/l (figure 7.1) and between 1 (figure 7.11) are shown with 95% and 99.9% confidence limits. Table 7.4 can be used to identify centres in these funnel plots. Haemoglobin in prevalent peritoneal dialysis The median Hb of on PD in the UK in 16 was 111 g/l (IQR 12 1, table 7.5). For PD, 79% had a Hb 5 g/l. Figure 7.12 shows the median Hb in PD by centre. Figure 7.13 shows the proportion of by centre with Hb within the Renal Association guideline range ( 1 g/l) and figure 7.14 shows the distribution of Hb within, above and below this range. Figures 7.15 and 7.16 are funnel plots showing the percentage of PD by centre in 16 with Hb 5 g/l and Hb 5 g/l and 4 1 g/l respectively. 176 Nephron 18;139(suppl1):165 1 Pyart/Gilg/Williams

13 Haemoglobin g/l N = 22,684 Upper quartile Hb Lower quartile 95 Chelms Edinb Derby Carlis 1 Belfast Redng 1 Wolve Krkcldy D&Gall 17 Colchr Glouc Shrew Dudley Ulster Bradfd Dorset Bristol Ports 1 Stoke Wrexm 1 Norwch 2 Liv Roy 3 Liv Ain Airdrie West NI Leic Exeter 8 L West 6 M RI Bangor 18 Inverns 2 Dundee 4 Newry Sthend Carsh Hull L Kings 1 Plymth Clwyd Donc Cardff Kent L Rfree Middlbr Brightn Sheff Prestn L Barts Oxford Swanse B QEH Newc Glasgw Klmarnk 1 Wirral York Nottm B Heart Sund Salford Leeds Antrim 1 Ipswi 3 L St.G 2 Basldn L Guys Covnt Stevng Truro Abrdn 1 England 1 N Ireland 1 Scotland Wales 1 UK Fig haemoglobin in prevalent treated with HD by centre in N = 22,684 Upper 95% Cl % with Hb > and <1 g/l Lower 95% Cl 35 Exeter Sthend 2 Dundee Truro 1 Ipswi Ulster Bristol York Krkcldy Shrew Carsh 1 Wirral Glouc 18 Inverns L Kings Donc Hull Clwyd Airdrie 8 L West 17 Colchr Nottm Abrdn B QEH Antrim Swanse Dorset 1 Norwch L Barts Middlbr Stevng 4 Newry Covnt 3 L St.G Brightn L Rfree B Heart Dudley Cardff 1 Stoke Kent Wrexm 3 Liv Ain 2 Basldn L Guys Derby Leeds Oxford Prestn D&Gall Ports West NI Newc Glasgw Carlis Bangor Leic 1 Belfast 6 M RI Sund Chelms Klmarnk Salford Redng 1 Wolve Sheff Edinb Bradfd 1 Plymth 2 Liv Roy 1 England 1 N Ireland 1 Scotland Wales 1 UK Fig Percentage of prevalent HD with Hb 5 g/l and 41 g/l by centre in 16 Hb >1 g/l Hb 1 g/l Hb < g/l 1 Exeter Sthend Dundee Truro Ipswi Ulster Bristol York Krkcldy Shrew Carsh Wirral Glouc Inverns L Kings Donc Hull Clwyd Airdrie L West Colchr Nottm Abrdn B QEH Antrim Swanse Dorset Norwch L Barts Middlbr Stevng Newry Covnt L St.G Brightn L Rfree B Heart Dudley Cardff Stoke Kent Wrexm Liv Ain Basldn L Guys Derby Leeds Oxford Prestn D&Gall Ports West NI Newc Glasgw Carlis Bangor Leic Belfast M RI Sund Chelms Klmarnk Salford Redng Wolve Sheff Edinb Bradfd Plymth Liv Roy England N Ireland Scotland Wales UK Fig Distribution of haemoglobin in prevalent treated with HD by centre in 16 Anaemia management in UK dialysis Nephron 18;139(suppl1):

14 95 Dotted lines show 99.9% limits Solid lines show 95% limits 75 Dotted lines show 99.9% limits Solid lines show 95% limits , 1, Number of with data in centre Fig Funnel plot of percentage of prevalent HD with Hb 5 g/l by centre in , 1, Number of with data in centre Fig Funnel plot of percentage of prevalent HD with Hb 5 g/l and 41 g/l by centre in Haemoglobin g/l Upper quartile Hb Lower quartile N = 3,25 Sund Dundee 2 Liv Roy Wrexm Derby Carlis 2 Kent Belfast Bristol Glouc 11 Chelms Stevng Glasgw Antrim Redng Norwch 1 Salford Sthend 1 Ports Shrew Bangor York Exeter 3 L St.G Clwyd Prestn Donc Swanse Krkcldy Middlbr D&Gall Newry 6 Carsh Truro Plymth 5 Wolve Dudley Oxford Liv Ain Bradfd Dorset Hull 1 Leic Stoke L Kings 2 L Barts Cardff Airdrie 1 L Rfree 2 M RI Ipswi 7 L West Sheff B QEH Edinb Leeds Wirral 2 Brightn Klmarnk Newc 2 Covnt B Heart Abrdn Basldn 1 Nottm L Guys 1 England N Ireland 3 Scotland Wales 1 UK Fig haemoglobin in prevalent treated with PD by centre in 16 N = 3,25 Upper 95% Cl % with Hb > and <1 g/l Lower 95% Cl 1 Middlbr Shrew York Antrim Airdrie Exeter 2 Brightn Belfast Wirral Liv Ain Edinb Bristol Clwyd 3 L St.G Leeds Sthend Carlis Oxford Hull Donc Krkcldy D&Gall 2 Kent Redng 1 L Rfree Truro L Kings Swanse Norwch Dorset Glouc Sheff Basldn Stevng 1 Salford Glasgw 6 Carsh 1 Leic Ipswi Newc 11 Chelms 2 L Barts B QEH Klmarnk Bangor Newry Dudley Plymth 1 Nottm 5 Wolve 1 Ports Wrexm 2 Covnt Cardff 2 Liv Roy Derby Dundee Prestn Stoke L Guys B Heart 7 L West Bradfd 2 M RI Abrdn Sund 1 England N Ireland 3 Scotland Wales 1 UK Fig Percentage of prevalent PD with Hb 5 g/l and 41 g/l by centre in Nephron 18;139(suppl1):165 1 Pyart/Gilg/Williams

15 Hb >1 g/l Hb 1 g/l Hb < g/l 1 Middlbr Shrew York Antrim Airdrie Exeter Brightn Belfast Wirral Liv Ain Edinb Bristol Clwyd L St.G Leeds Sthend Carlis Oxford Hull Donc Krkcldy D&Gall Kent Redng L Rfree Truro L Kings Swanse Norwch Dorset Glouc Sheff Basldn Stevng Salford Glasgw Carsh Leic Ipswi Newc Chelms L Barts B QEH Klmarnk Bangor Newry Dudley Plymth Nottm Wolve Ports Wrexm Covnt Cardff Liv Roy Derby Dundee Prestn Stoke L Guys B Heart L West Bradfd M RI Abrdn Sund England N Ireland Scotland Wales UK Fig Distribution of haemoglobin in prevalent treated with PD by centre in 16 Dotted lines show 99.9% limits Solid lines show 95% limits Dotted lines show 99.9% limits Solid lines show 95% limits Number of with data in centre Fig Funnel plot of percentage of prevalent PD with Hb 5 g/l by centre in Number of with data in centre Fig Funnel plot of percentage of prevalent PD with Hb 5 g/l and 41 g/l by centre in 16 1 Bangor Edinb Exeter Bristol West NI Ulster Shrew Sthend Belfast Ports Stoke Derby Liv Roy Wirral Dundee Truro Plymth Carlis Wolve Dorset Glouc Chelms Wrexm Brightn Carsh L West Klmarnk Cardff Sund Prestn Salford Bradfd B QEH Newry Liv Ain L St.G Redng L Kings Krkcldy Donc L Rfree Kent Oxford Glasgw Hull Middlbr Stevng Sheff York Covnt Abrdn B Heart Nottm M RI Ipswi Colchr Swanse Leic Antrim Dudley L Barts Norwch Newc Airdrie Leeds Basldn L Guys Clwyd England N Ireland Scotland Wales UK Prevalent dialysis Incident dialysis Fig Percentage of incident and prevalent dialysis with Hb 5 g/l by centre in 16 Anaemia management in UK dialysis Nephron 18;139(suppl1):

16 Relationship between Hb in incident and prevalent dialysis The relationship between the percentage of incident and prevalent with Hb 5 g/l is shown in figure As expected, all centres had a higher percentage of prevalent achieving a Hb 5 g/l than of incident. Changes in achievement of Hb 5 g/l by year of start in both incident and prevalent is shown in figure This shows a falling trend in the proportion of achieving a Hb 5 g/l over the last decade. Ferritin in prevalent haemodialysis The median and IQR for serum ferritin for treated with HD are shown in figure The percentages with serum ferritin 5 mg/l,. mg/l to mg/l, and mg/l are shown in figures 7., 7.21 and 7.22 respectively. The median serum ferritin in HD was 41 mg/l with 94% of HD achieving a serum ferritin 5 mg/l. Ferritin in prevalent peritoneal dialysis The median and IQR for serum ferritin for treated with PD are shown in figure The percentages with serum ferritin 5 mg/l,. mg/l to mg/l, and mg/l are shown in figures 7.24, 7.25 and 7.26 respectively. The median serum ferritin in PD was 6 mg/l with 88% of PD achieving a serum ferritin 5 mg/l. Erythropoiesis stimulating agents in prevalent haemodialysis The median dose of ESA for prevalent HD in England, Wales and Northern Ireland was 7,7 IU/week Upper 95% Cl % with Hb > g/l Lower 95% Cl Incident Prevalent Year Fig Percentage of incident and prevalent dialysis ( ) with Hb 5 g/l 1, 1, 1, N = 22,127 Upper quartile ferritin Lower quartile Ferritin μg/l 1 Middlbr Carlis Ulster 2 Plymth Airdrie L Barts 4 Prestn Bristol 3 Stevng 15 Colchr D&Gall 1 Ipswi West NI 3 Abrdn Norwch 1 L Rfree Chelms Dorset Bradfd 1 L Guys 1 Kent 1 Glasgw 1 Wolve 1 Redng 1 Antrim 3 Liv Ain 1 Brightn Leeds Sheff Derby Nottm 1 L Kings Belfast 1 Krkcldy Wrexm Edinb 1 Wirral 1 Ports 1 Antrim Hull 5 L St.G 1 Liv Roy Truro Newry Donc York Newc B QEH Bangor Covnt 26 Inverns Clwyd Shrew 2 Glouc Leic 1 Carsh 9 L West Exeter Dudley Cardff Oxford 2 Stoke Sthend 2 B Heart Swanse 2 Dundee 17 Sund 1 Klmarnk 2 Basldn 4 England N Ireland 2 Scotland Wales 3 UK Fig ferritin in prevalent treated with HD by centre in 16 1 Nephron 18;139(suppl1):165 1 Pyart/Gilg/Williams

17 Upper 95% Cl % with ferritin > μg/l Lower 95% Cl N = 22,127 D&Gall Wrexm Sthend 15 Colchr Chelms Bradfd 3 Abrdn Bristol 1 Redng 1 Middlbr West NI Truro Dorset Donc Derby 1 Brightn Shrew Belfast 1 L Rfree Nottm 3 Stevng 15 M RI Sheff 1 Ipswi Ulster Clwyd York Carlis Airdrie 2 Plymth L Barts Leeds 1 Kent Covnt 1 Antrim Norwch B QEH 4 Prestn Hull 1 L Kings 9 L West 1 Ports 1 L Guys 5 L St.G 1 Wirral Newry Exeter 2 Glouc Bangor 1 Carsh 1 Wolve Newc Edinb 1 Glasgw 3 Liv Ain Leic Cardff 1 Liv Roy 2 Stoke 26 Inverns Dudley Oxford 2 B Heart 17 Sund 1 Klmarnk Swanse 1 Krkcldy 2 Dundee 2 Basldn 4 England N Ireland 2 Scotland Wales 3 UK Fig. 7.. Percentage of prevalent HD with ferritin 5 mg/l by centre in 16 N = 22,127 Upper 95% Cl % with ferritin > and < μg/l Lower 95% Cl 1 Sthend York Dudley 1 Carsh Covnt B QEH Exeter Shrew Clwyd Truro 9 L West Leic Cardff 1 Ports 1 Wirral Nottm Donc Hull 5 L St.G Bangor 1 Klmarnk Sheff 2 Glouc Oxford Wrexm 26 Inverns 2 Dundee 2 Stoke 1 Redng Derby 1 Brightn 2 B Heart Belfast 1 Antrim Newc 17 Sund Leeds 15 M RI Newry Dorset Bradfd Chelms Edinb Swanse 1 L Kings 3 Abrdn 1 Liv Roy 1 Wolve 1 L Rfree 1 Kent Norwch 1 L Guys 1 Glasgw 2 Basldn 15 Colchr 1 Ipswi 3 Liv Ain Airdrie 3 Stevng D&Gall West NI 1 Krkcldy 4 Prestn 2 Plymth Bristol L Barts Ulster 1 Middlbr Carlis 4 England N Ireland 2 Scotland Wales 3 UK Fig Percentage of prevalent HD with ferritin. and mg/l by centre in 16 Upper 95% Cl N = 22,127 % with ferritin >μg/l Lower 95% Cl 1 2 Basldn York Sthend 2 Dundee Dudley Exeter 1 Carsh Covnt 1 Klmarnk 26 Inverns B QEH Leic Cardff Shrew Oxford 9 L West 1 Ports 2 Stoke Nottm 2 B Heart 1 Wirral Clwyd Truro 2 Glouc Bangor Swanse Chelms 17 Sund 5 L St.G Hull Donc Leeds Sheff 1 Brightn Newry Newc 1 Wolve 1 Antrim Wrexm Edinb 1 L Kings 1 Liv Roy Dorset Bradfd 1 Redng D&Gall Belfast 15 M RI L Barts 1 Glasgw 1 L Guys Derby Norwch 1 Kent Bristol 1 L Rfree 1 Krkcldy 3 Liv Ain 1 Ipswi 3 Abrdn 15 Colchr West NI Ulster 3 Stevng 4 Prestn Airdrie 2 Plymth Carlis 1 Middlbr 4 England N Ireland 2 Scotland Wales 3 UK Fig Percentage of prevalent HD with ferritin mg/l by centre in 16 Anaemia management in UK dialysis Nephron 18;139(suppl1):

18 1, N = 2,843 Upper quartile ferritin Lower quartile Ferritin μg/l 6 Prestn 3 L Rfree 7 Brightn Nottm Sheff Ipswi 1 Derby 3 Plymth Norwch Edinb 8 L West Wirral Clwyd Newc 1 Ports 2 Redng 5 Abrdn 9 Middlbr Antrim Carlis 4 Leic Hull Belfast Donc Leeds 5 Kent 4 Klmarnk Newry 5 Bristol 7 Krkcldy Liv Ain 5 Airdrie 1 Stoke 15 Dorset 4 M RI B QEH 11 L Barts 6 Stevng Exeter 2 Swanse 6 Sund Bradfd 3 L St.G Wrexm Shrew York 1 Oxford 2 Liv Roy 18 Truro 6 B Heart L Kings 3 Covnt 8 Dundee 6 L Guys 13 Carsh Glasgw 9 Glouc Sthend 11 Chelms 16 Cardff 9 Wolve Basldn Bangor 19 Dudley 8 England N Ireland 6 Scotland 7 Wales 7 UK Fig ferritin in prevalent treated with PD by centre in 16 Upper 95% Cl % with ferritin > μg/l N = 2,843 Lower 95% Cl Antrim 6 Stevng Wirral Ipswi Clwyd Liv Ain 5 Abrdn Leeds 1 Ports Edinb Hull 15 Dorset Wrexm Donc Sheff 4 M RI 1 Derby Nottm Belfast Norwch 9 Middlbr 5 Airdrie 1 Oxford Newry 6 Prestn 6 L Guys 3 Plymth 2 Swanse 4 Klmarnk 3 L Rfree 5 Bristol Exeter 3 L St.G 1 Stoke Newc 8 L West B QEH Carlis 4 Leic 2 Redng 5 Kent 7 Brightn Shrew 18 Truro 2 Liv Roy L Kings York 11 L Barts 16 Cardff 6 B Heart 3 Covnt 9 Glouc Glasgw 13 Carsh 6 Sund Bradfd 7 Krkcldy Sthend 11 Chelms Basldn 19 Dudley 8 Dundee Bangor 9 Wolve 8 England N Ireland 6 Scotland 7 Wales 7 UK Fig Percentage of prevalent PD with ferritin 5 mg/l by centre in 16 N = 2,843 Upper 95% Cl % with ferritin > and < μg/l Lower 95% Cl 1 6 L Guys 1 Oxford 18 Truro Liv Ain Exeter Newry Antrim 3 L St.G Leeds 16 Cardff Donc 15 Dorset Wrexm L Kings 4 M RI 6 Stevng Shrew Hull Clwyd 13 Carsh B QEH 9 Glouc 1 Stoke 2 Swanse 2 Liv Roy Belfast Sthend Wirral Basldn 5 Abrdn 6 B Heart Norwch 5 Airdrie 4 Leic 19 Dudley 1 Ports Newc York 2 Redng 3 Covnt Edinb 5 Kent 5 Bristol 4 Klmarnk 11 Chelms 11 L Barts 9 Middlbr Bangor Carlis Ipswi Glasgw 1 Derby 3 Plymth 8 Dundee Nottm 8 L West Sheff Bradfd 9 Wolve 7 Krkcldy 7 Brightn 3 L Rfree 6 Prestn 6 Sund 8 England N Ireland 6 Scotland 7 Wales 7 UK Fig Percentage of prevalent PD with ferritin. and mg/l by centre in Nephron 18;139(suppl1):165 1 Pyart/Gilg/Williams

19 1 Upper 95% Cl N = 2,843 % with ferritin > μg/l Lower 95% Cl Newry Sthend 6 Stevng Basldn 18 Truro 9 Glouc Leeds Bangor 5 Abrdn 13 Carsh L Kings 4 Leic 16 Cardff 4 M RI 5 Bristol 1 Oxford 19 Dudley 3 L St.G 9 Wolve 15 Dorset Donc 11 Chelms Bradfd Exeter 6 B Heart 2 Liv Roy B QEH Wirral 6 L Guys Shrew 2 Redng Antrim 1 Stoke Wrexm 5 Kent 4 Klmarnk Hull 8 Dundee Newc 5 Airdrie Nottm York Glasgw 3 Covnt 2 Swanse Carlis 3 Plymth Belfast 1 Ports 1 Derby Clwyd Sheff 11 L Barts 8 L West Edinb Liv Ain 6 Sund Norwch 9 Middlbr 7 Krkcldy Ipswi 7 Brightn 3 L Rfree 6 Prestn 8 England N Ireland 6 Scotland 7 Wales 7 UK Fig Percentage of prevalent PD with ferritin mg/l by centre in 16 with wide variation between centres from 4,2 IU/week (Ulster) to 13,39 IU/week (Reading) (table 7.4). There was very little correlation between median ESA dose and either median Hb (figure 7.27) or compliance with Hb 1 g/l (figure 7.28). For these analyses only with both Hb and ESA data were included. Erythropoiesis stimulating agents in prevalent peritoneal dialysis The median dose of ESA for prevalent PD in England, Wales and Northern Ireland was 4, IU/week (table 7.5). ESA prescription and association with achieved haemoglobin Figures 7.9 and 7.14 show the distribution of Hb concordance with the Renal Association guideline ( 1 g/l). Not all with Hb.1 g/l were receiving ESA. The consensus was that these should not be included in the group of not meeting this target. There are two reasons: first, the high Hb remains largely outside the control of the clinician; secondly, the trials suggesting it may be detrimental to achieve a high Hb in renal were based upon treated with ESAs [5 7]. Figures 7.29 and 7. therefore show the percentages of HD and PD in each centre whose Hb lies below, within or above the Renal Association guideline range. For those with Hb.1 g/l it also differentiates between those receiving, or not, ESAs. In centres with useable ESA data, 21.2% of HD had a Hb.1 g/l and 4.1% had a Hb.1 g/l and were not receiving ESAs. For PD 23.1% had a Hb.1 g/l and 12.4% had a Hb.1 g/l and were not receiving ESAs. Hb g/l Compliance with Hb 1 g/l , 5, 7, 9, 11, 13, ESA dose (IU/week) Fig Hb versus median ESA dose in prevalent HD on ESA, by centre in , 5, 7, 9, 11, 13, ESA dose (IU/week) Fig Compliance with Hb 1 g/l versus median ESA dose in prevalent HD on ESA, by centre in 16 Anaemia management in UK dialysis Nephron 18;139(suppl1):

20 Hb >1 g/l not on ESA Hb >1 g/l on ESA Hb 1 g/l Hb < g/l 1 Exeter Sthend Ulster Bristol York Wirral Glouc L Kings Donc Nottm B QEH Antrim Swanse Dorset Norwch Middlbr Stevng Newry Covnt Brightn B Heart Kent Basldn Leeds Oxford Prestn West NI Newc Carlis Leic Belfast Sund Chelms Redng Wolve Sheff Bradfd England N Ireland Wales E, W & NI Fig Distribution of haemoglobin in prevalent treated with HD and the proportion of with Hb.1 g/l receiving ESA by centre in 16 Hb >1 g/l not on ESA Hb >1 g/l on ESA Hb 1 g/l Hb < g/l 1 Middlbr York Antrim Exeter Belfast Wirral Bristol Clwyd Leeds Sthend Carlis Oxford Hull Donc Kent L Kings Swanse Norwch Dorset Glouc Sheff Basldn Stevng Salford Leic Chelms B QEH Newry Nottm Wolve Covnt Prestn B Heart Bradfd Sund England N Ireland Wales E, W & NI Fig. 7.. Distribution of haemoglobin in prevalent treated with PD and the proportion of with Hb.1 g/l receiving ESA by centre in 16 ESA prescription: age and modality associations The proportion of on ESA was higher for HD (%) than for PD (%). This difference was maintained across all age groups (figure 7.31). The proportion of with Hb 5 g/l without requiring an ESA is shown (by age group and modality) in figure ESAs and time on renal replacement therapy The percentage of on ESA by time on RRT and dialysis modality is shown in figure This is a cross-sectional analysis of at the end of 16. Patients who had previously changed RRT modality were included in the analysis. The proportion of PD receiving ESA rises with duration of RRT from % after 3 12 months to 78% after ten or more years. Resistance to ESA therapy The Renal Association guidelines define resistance to ESA therapy as failure to reach the target Hb level despite sc epoetin dose IU/kg/week (4 IU/kg/ week iv epoetin) or darbepoetin dose >1.5 mcg/kg/ week [1]. Figure 7.34 shows the frequency distribution 184 Nephron 18;139(suppl1):165 1 Pyart/Gilg/Williams

21 (95% CIs) HD PD (95% CIs) HD PD Age range (years) Fig Percentage of dialysis on ESA, by age group and treatment modality in Age range (years) Fig Percentage of whole cohort (16) who were not on ESA and had Hb 5 g/l, by age group and treatment modality of weekly ESA dose adjusted for weight by treatment modality. s included in this analysis were restricted to those with good completeness for weight (.75%) and ESA data. Thirty two centres were included for HD data and 16 centres for PD. The prevalence of PD receiving over IU/kg/week was 3.% with 5.7% of HD receiving more than IU/kg/week and 1.2% more than 4 IU/kg/week. Success with guideline compliance The percentage of prevalent dialysis achieving a Hb 5 g/l by year ( ) is shown in figure This has shown a gradual fall in achievement of this guideline over the last decade. Table 7.6 shows that the percentage of all treated with an ESA and having Hb.1 g/l ranged between 8 32% for HD and between 32% for PD. Table 7.7 shows the percentage completeness for ESA type, dose, route and frequency for centres reporting ESA data. Even for this group of centres which is already restricted to those with useable ESA data, completeness of frequency and administration route averaged below %. Roughly half of the centres had very good completeness for these items and the other half did not submit at all. HD PD on ESA (95% CIs) HD PD 3 months to <1 year 1 2 years 2 3 years 3 5 years 5 1 years >1 years Time on RRT Fig on ESA by time on RRT in < < <1 ESA dose (IU/kg/week) Fig Frequency distribution of mean weekly ESA dose corrected for weight in 16 1 < <4 4 or more Anaemia management in UK dialysis Nephron 18;139(suppl1):

22 Table 7.6. Percentage of prevalent with Hb.1 g/l and on ESA and percentage of with serum ferritin, mg/l and on ESA, by modality HD PD % with Hb.1 g/l and on ESA % with ferr, mg/l and on ESA % with Hb.1 g/l and on ESA % with ferr, mg/l and on ESA England B Heart B QEH Basldn Bradfd Brightn 17 2 Bristol Carlis Chelms Covnt Donc 12 3 Dorset Exeter Glouc Hull 3 2 Kent L Kings Leeds Leic Middlbr 1 1 Newc 16 4 Norwch Nottm Oxford Prestn Redng 1 Salford 16 Sheff Stevng Sthend Sund Wirral Wolve York N Ireland Antrim Belfast 2 18 Newry Ulster 15 1 West NI 21 2 Wales Clwyd Swanse England N Ireland Wales E, W & NI Blank cells centres excluded from analyses due to poor data completeness, small numbers with data or incomplete ESA data 186 Nephron 18;139(suppl1):165 1 Pyart/Gilg/Williams

23 Table 7.7. Percentage completeness for type, dose, route and frequency of administration of ESA HD PD N on ESA % with drug type % with dose % with frequency % with administration route N on ESA % with drug type % with dose % with frequency % with administration route England B Heart B QEH Basldn Bradfd Brightn 367 Bristol Carlis 67 Chelms Covnt 281 Donc Dorset Exeter Glouc Hull Kent L Kings Leeds Leic Middlbr Newc 232 Norwch Nottm Oxford Prestn Redng 2 Salford 65 Sheff Stevng Sthend Sund 1 Wirral Wolve York N Ireland Antrim Belfast Newry Ulster 89 West NI Wales Clwyd 8 Swanse 4 35 Blank cells data not useable or not available Discussion Anaemia is one of the major comorbidities associated with CKD. It can lead to a debilitating reduction in exercise capacity and quality of life as well as left ventricular dysfunction and heart failure. While the degree of renal impairment affects the likelihood of any patient developing anaemia [8], all should be carefully Anaemia management in UK dialysis Nephron 18;139(suppl1):