UK survey of patient and caregiver perspectives on the impact of chronic kidney disease-associated anaemia

Abstract

Objective

Chronic kidney disease (CKD)-associated anaemia has substantial biopsychosocial impacts. This study explores the impact of CKD-associated anaemia and treatment preferences from the patient perspective.

Design

Cross-sectional survey.

Setting

Anonymised online survey implemented by Ipsos UK on behalf of the National Kidney Federation and GSK from October 2022 to January 2023.

Participants

Data were collected from UK adults living with CKD (self-reported).

Primary and secondary outcome measures

Outcome measures were exploratory and not predefined. The cross-sectional survey was designed to explore the biopsychosocial impact of living with anaemia on individuals with CKD; their unmet needs; the treatment strategies typically implemented and the associated barriers/facilitators to adherence; the healthcare professional–patient relationship with regard to anaemia diagnosis and management.

Results

Of 101 participants, 90 (89%) were patients with CKD and 11 (11%) were informal carers. 96 (95%) participants reported symptom(s) relevant to their experience of CKD. 88 (87%) participants reported symptom(s) associated with anaemia and 61 (64%) expressed an impact on daily life including 18 (19%) unable to perform daily activities, 13 (14%) unable to go to work and 9 (9%) reporting poor social life/interactions. 85 (84%) participants reported they have received treatment for anaemia: intravenous iron (n=55, 54%), iron tablets (n=29, 29%), erythropoietin-stimulating agents (ESAs) via an autoinjector (n=28, 28%), ESA injections via a syringe (n=24, 24%), ESA injections via a dialysis machine (n=17, 17%), folic acid (n=22, 22%) and blood transfusion (n=17, 17%). Six of seven (86%) participants who received their ESA from a healthcare professional at home preferred injections whereas 13/27 (48%) participants who injected themselves at home preferred oral tablets.

Conclusions

There is not a ‘one-size-fits-all’ approach to the management of CKD-associated anaemia. A personalised approach incorporating the treatment preferences of the individual should be explored when discussing treatment options.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Cross-sectional study of 101 people self-reporting their chronic kidney disease (CKD) diagnosis (no link to clinical records or objective diagnoses).

• The survey was designed with close patient engagement and oversight to ensure the content was accessible and relevant to the CKD population.

• The inclusion criteria were broad to encompass all stages of CKD and the survey was distributed through the National Kidney Federation newsletter, social media and patient network support groups to enhance uptake.

• Participation relied on access to and use of the internet, engagement with the National Kidney Federation, with an associated £15 incentive for participation.

Introduction

Chronic kidney disease (CKD) is a public health emergency; in the UK alone, approximately 3.25 million people are living with CKD stages 3–5,¹ with an additional 70 000 people receiving kidney replacement therapy.² CKD-associated anaemia is common and impacts the majority of people living with CKD.

Health-related quality of life is significantly impaired by CKD-associated anaemia, with individuals’ lives heavily impacted in a number of ways,³ contributing to reduced work productivity and increased health economic burden.^{4 5} CKD-associated anaemia increases the risk of mortality, hospitalisation and major cardiovascular events; the risk corresponds to anaemia severity.⁶ Individuals experience intrusive symptoms, including breathlessness, fatigue and reduced cognitive function and exercise capacity.⁷

Once CKD-associated anaemia has been confirmed, management strategies involve iron therapy and erythropoietin-stimulating agents (ESAs), with sparing use of red blood cell transfusions.⁸ The development of ESAs since the 1980s has transformed the management of CKD-associated anaemia; partial correction of haemoglobin levels with ESAs is associated with improvements in quality of life and physical function,^{4 9 10} surrogates for cardiovascular disease,¹¹ with a substantial reduction in blood transfusion requirements and associated complications.⁸ There are also health economic benefits, with reduced healthcare resource use and lower costs in individuals receiving ESAs for CKD-associated anaemia compared with those not receiving ESAs.⁴

ESAs are delivered intravenously during haemodialysis or subcutaneously for predialysis and peritoneal dialysis cohorts. Subcutaneous administration often relies on patient self-administration, typically on a weekly basis. Tolerability and capacity to self-inject medication is a barrier to ESA therapy¹² and many people require assistance from healthcare professionals (HCPs) and informal carers.¹³

Further progress has been made with management options for CKD-associated anaemia. Hypoxia-inducible factor prolyl hydroxylase enzyme inhibitors (HIF-PHIs) facilitate the accumulation of HIF; this stimulates endogenous erythropoietin (EPO) generation and iron mobilisation into the bone marrow,¹⁴ eliminating the requirement for exogenous EPO administration and possibly reducing iron therapy requirements.¹⁵ HIF-PHIs have demonstrated clinical efficacy for anaemia management in both predialysis and dialysis cohorts and can be administered orally, avoiding the need for self-administration, carer-supported or HCP-supported injectable therapy.¹⁵

The aim of this work is to increase awareness of the impact of CKD-associated anaemia and treatment preferences through the following objectives:

1. Understand the biopsychosocial impact of living with anaemia on individuals with CKD.

2. Identify the unmet needs of individuals living with CKD and anaemia.

3. Establish the treatment strategies typically implemented and the barriers/facilitators to accessing and adhering to these treatments.

4. Understand the HCP–patient relationship with regard to anaemia diagnosis and management.

Methods

This cross-sectional study was conducted by Ipsos UK on behalf of the National Kidney Federation (NKF) and GSK. Data were collected using an online survey via Dimensions,¹⁶ developed and implemented by Ipsos UK from October 2022 to January 2023. (see online supplemental material).

Patient and public involvement

Author JR, patient engagement specialist and lived experience expert, was consulted on the project throughout its development.

Participants

Adults (≥18 years) living with CKD in the UK, and their caregivers, were eligible for participation with a target sample size of 100 participants. An invitation to complete the online survey was distributed through the NKF newsletter, social media and patient network support groups. The survey was completed in one sitting with an estimated completion time of 15 min. All participants received a £15 incentive on completion.

Data collection

The survey did not collect any identifiable data and all participants maintained anonymity. The survey included demographics (gender, age in years, geographical region and employment status); experience of living with CKD (comorbidity, length of time in years since diagnosis, treatment and symptoms) and anaemia (information received, sources of information, treatments received, symptoms, unmet needs and impact on daily life). The survey can be found in online supplemental material.

Data analysis

Completed surveys were analysed manually. Responses from those completing the questionnaire in under 3 min were removed if the quality of the data was poor or if the answer did not make sense for the question. Only the participants who completed the entire survey were included in the analysis. Where a rating scale was used, ‘top two box scores’, in which the top two responses are combined to give a single score, were analysed to summarise the data.

The results represent pooled data from the entire participant population (ie, patients and caregivers answering on behalf of the person they care for) unless otherwise stated. Open-ended questions were implemented to gather spontaneous responses and provide further context and depth to answers. Potential associations between both CKD stage and participant age, and the reporting of symptoms which may be due to anaemia, were explored with likelihood ratios. Statistical significance was accepted at p<0.05. Statistical analysis of data was performed by using the Statistical Package for Social Sciences (SPSS for Windows, V.28.0, IBM).

Results

In total, 101 participants completed the online survey; 90 (89%) were patients with CKD and 11 (11%) were informal carers for individuals living with CKD, who completed the survey on their behalf. 55 (54%) of the patients were female, 46 (46%) were aged between 51 and 70 years and 39 (39%) were retired. The majority of the patients were from London (n=25, 25%). Regarding CKD status, 35 (35%) of patients had been diagnosed 2–5 years ago and 34 (34%) were living with CKD stage 5, 14 (14%) with CKD stage 4 and 27 (27%) with CKD stage 3. High blood pressure (n=51, 50%), high cholesterol (n=29, 29%) and diabetes type 1 or type 2 (n=19, 19%) were the most frequently reported comorbidities from the precoded list. Full patient demographics are reported in table 1.

Table 1. Patient demographics.

Variable	Proportion of cohort (%); total N=101*
Age
18–30 years	15
31–50 years	22
51–70 years	46
≥71 years	18
Gender
Male	46
Female	55
Employment
Full-time employment (≥30 hours per week)	24
Part-time employment (8–29 hours per week)	20
Student	3
Unemployed and seeking work	1
Not in paid employment—housemaker	3
Not working because I receive disability payments	11
Retired	39
UK region
London	25
East England	16
North West	15
South West	11
Yorkshire and Humber	9
South East	8
West Midlands	5
Scotland	5
North East	4
East Midlands	3
Other health conditions
High blood pressure	51
High cholesterol	29
Type 2 diabetes	11
Type 1 diabetes	8
Heart failure	7
Coronary heart disease	6
Peripheral arterial disease	2
None of the above	20
Length of time since CKD diagnosis
Less than 1 year ago	13
2–5 years ago	35
6–10 years ago	14
11–15 years ago	11
More than 16 years ago	26
I do not know	2
Current CKD stage
Stage 1–90% or higher	7
Stage 2–60%–89% (mild)	14
Stage 3–30%–59% (moderate)	27
Stage 4–15%–29% (severe)	14
Stage 5–below 15% (end-stage renal failure)	34
I do not know	5

^*n=90 patients answering on behalf of themselves and 11 caregivers answering on behalf of the patient they care for.

CKD, chronic kidney disease

Symptoms of anaemia and impact on daily life

96 (95%) participants reported symptom(s) relevant to their experience of CKD. 88 (87%) participants reported currently experiencing or previously experiencing at least one or more symptoms associated with anaemia from a precoded list (feeling very tired, feeling weak/lack of strength, shortness of breath during activity, shortness of breath during rest and pale skin or dizziness). Figure 1 shows the full breakdown of symptoms experienced. There was no significant association between the experience of symptoms which may be due to anaemia and both: CKD stage, LX²(4)=8.365, p=0.079; and participant age, LX²(2)=3.794, p=0.150.

Figure 1. Symptoms reported by the study participants (N=101) at the time of survey completion or in the past. 87% of participants reported symptoms in keeping with suspected anaemia. Question A6 of survey (see online supplemental material).

Of the 96 (95%) participants who reported symptom(s) relevant to their experience of CKD currently or in the past, 61 (64%) reported, through open-ended responses, that symptoms impacted their lifestyle, with 18 (19%) expressing an inability to perform daily activities, 13 (14%) expressing an inability to go to work/maintain professional life and 9 (9%) reporting poor social life/interactions due to their symptoms. Participant open-ended responses reported the loss of independence and consequent isolation:

I lack activity and my independence. I need support in every area of my life and I have become more isolated. I can no longer carry out most of my previously normal daily activities. [Patient, female, aged 51 to 70 years]

Of these 96 respondents, 43 (45%) reported a psychological and emotional impact of their symptoms, with 20 (21%) feeling sad and depressed and 7 (7%) feeling anxious about their health and the future (spontaneous answers, not from a precoded list). Vulnerability and health anxiety featured in the participant open-ended responses:

[I feel] vulnerable to infection, aware of other disease around me, anxious waiting for my kidney function to deteriorate and anxious what this will have on my future. [Patient, male, aged 51 to 70 years]

Further participant quotations are presented in box 1 to reflect how symptoms of CKD, particularly those that may be due to CKD-associated anaemia, impact daily life.

Box 1. A selection of quotes from participants’ free text (question A7 of the survey, see online supplemental material) illustrating the intrusive nature of symptoms.

Impact of chronic kidney disease-associated symptoms experienced by participants on their daily lives

I do worry about the future which can make me feel down sometimes. I am not able to work like I used to which brings financial pressure. I get frustrated because I get very tired sometimes which can make it more difficult to do some things.

Fatigue suffered from kidney failure while on dialysis and post-transplant is my biggest day to day symptom. It has affected my life greatly, from not having the energy to complete certain activities and days out.

Chronic illness affects every aspect of your life. People say oh you look well but inside you are dragging yourself round. I feel like I let down my family because I can’t do as much as I used to.

Not being able to do anything you once could is mentally very difficult and put strains on all relationships.

These symptoms make me feel useless, worthless and depressed leading to me not going out of the house apart from to appointments and i never used to be like this.

I need to plan my activities so that they are manageable without me getting too tired. I had to stop working full time and reduce my hours when I went into Stage 5five kidney disease… initially to 4 days a week days a week, and then 2 days a week days a week.

My life has been negatively affected by my condition. I have very limited activity due to fatigue, weakness, shortage of breath. My life has been totally changed. I lack activity and my independence. I need support in every area of my life. I have become more isolated. My mental well-being has suffered. I can no longer carry out most of my previously normal daily activities.

The fatigue is debilitating: you think you feel ok but you can't move because you don't have the energy to do so.

It made getting up in a morning a real struggle. I had difficulty concentrating at work and I couldn't run around and play with my children because I was so tired and got out of breath. It had a big impact on what we could do as a family.

I look back sometimes and it doesn’t seem real that I could run upstairs, work full time and manage a home and children. My life becomes more and more shrunken.

Participant knowledge of CKD-associated anaemia

59 (58%) participants reported experiencing anaemia as a potential complication of CKD and 42 (42%) did not. When asked about information they have been told about anaemia, 30 (30%) participants reported they had not been told anything about anaemia; of these 30 participants, 12 (40%) reported experiencing anaemia as a potential complication of CKD. All participants were asked about the type of information they had been told about anaemia; the information focused on the typical disease impact and symptoms (n=39, 39%), and treatment (n=25, 25%) (spontaneous answers, not from a precoded list). Regarding treatment, information about the need for iron replacement therapy was reported as being more frequently provided (n=19, 19%) than information about EPO injections (n=7, 7%) (spontaneous answers, not from a precoded list). Participant open-ended responses reflected the information provided.

[Anaemia] causes a lot of fatigue and makes CKD symptoms worse. Might need injections, iron transfusion, can prevent you from being ready for transplant. [Patient, female, 18 to 30 years]

I know that anaemia is caused by a lack of iron in the body, I think it is to do with red blood cells. [Patient, female, aged 51 to 70 years]

Among the participants who received information about anaemia (n=62), patient websites (n=37, 60%; eg, NKF, Kidney Care UK and Kidney Research UK), renal doctors (n=37, 60%) and renal specialist nurses (n=33, 53%) were the most frequently reported as helpful sources of information about anaemia (from a precoded list). Peer support networks (n=13, 21%) and other renal health professionals (n=17, 27%; eg, dieticians) were also popular sources of helpful information about anaemia.

Further participant quotations are presented in box 2 to reflect the information participants have received about anaemia.

Box 2. A selection of quotes from participants’ free text (question B1 of the survey, see online supplemental material) illustrating information received by participants about anaemia.

Information participants have received about anaemia from any information source

I was informed of my low red blood cell count at the clinic and advised to have an iron infusion. This has now been repeated on several occasions.

Anaemia is the lack of red blood cells which can affect my energy levels and make me look pale. Anaemia is not good for my health generally.

Causes a lot of fatigue and makes chronic kidney disease (CKD) symptoms worse. If to do with CKD, won’t be managed by diet alone. Might need injections, iron, transfusions. Can prevent you being ready for transplant.

Just told I am anaemic and have periodically needed iron tables.

I was told that my iron levels are naturally below the usual baseline, although i have never been diagnosed with anaemia.

Googled symptoms.

I know it is not unusual to develop anaemia when one has CKD. Regular blood tests have identified anaemia and I’ve been successfully treated with iron tablets. My renal consultant regularly monitors iron levels through blood tests. I had been feeling more tired than usual so it was helpful to know the tiredness was due to the anaemia.

Community dialysis and general practitioner service monitor bloods and advise on medication. Iron tablets were suggested but endogenous erythropoietin injections are now given monthly.

None.

It is a serious thing and has to be taken care of by the professional.

Anaemia management

85 (84%) participants reported they had received treatment related to their CKD and anaemia. Treatments included intravenous iron (n=55, 54%), iron tablets (n=29, 29%), ESA/EPO via an autoinjector (n=28, 28%), ESA/EPO injections via a syringe (n=24, 24%), ESA/EPO injections via a dialysis machine (n=17, 17%), folic acid (n=22, 22%) and blood transfusion (n=17, 17%). In total, 55 (54%) participants had received ESA/EPO treatment via any modality and 49 (49%) had received injectable ESA/EPO treatment via an autoinjector or syringe during their kidney care. Participants expressed concern about the impact of anaemia management:

If [anaemia] is to do with CKD, won’t be managed by diet alone. Might need injections, blood transfusions, and can prevent you from being ready for a transplant. [Patient, female, aged 18–30]

Currently being investigated to see if I have developed EPO antibodies. I’m also aware of problems with blood transfusion. [Patient, female, aged 31–50]

Most participants who reported receiving ESA/EPO treatment categorised their experience as ‘very or fairly good’: 24/28 (86%) of those who received ESA/EPO treatment via an autoinjector; 17/24 (71%) of those who received ESA/EPO via a syringe; and 14/17 (82%) of those who received ESA/EPO via a drip. 38 (69%) participants who had received ESA/EPO injections or via a dialysis machine for their CKD and anaemia (n=55) felt better afterwards. There were improvements in five aspects of daily living as a result of receiving ESA treatment (figure 2).

Figure 2. Improvements in aspects of daily living from participants who had received ESA/EPO via any modality (n=55). ‘Before’ refers to prior to receiving ESA/EPO via any modality and ‘after’ refers to following treatment with ESA/EPO via any modality. Question B4B of survey (see online supplemental material). EPO, erythropoietin; ESA, erythropoietin-stimulating agent.

49 (49%) participants reported receiving subcutaneous ESA/EPO injections via an autoinjector or syringe; of those, 15 (31%) participants reported administration by an HCP and 32 (65%) reported self-administration or administration by a family member at home. Of those receiving ESA/EPO injections at home (n=32), 16 (50%) reported receiving detailed training via show-and-tell with a nurse or injecting themselves with renal nurse assistance. Five (31%) participants who received this detailed training felt ‘somewhat or very uncomfortable’ self-administering their injection after receiving training.

20 (41%) participants who received subcutaneous ESA/EPO injections via an autoinjector or syringe (n=49) reported they had either missed an injection (n=4, 8%) or experienced a delay in receiving their treatment (n=16, 33%). Seven (14%) participants discarded an injection due to leaving the ESA/EPO outside of the refrigerator when not in use.

Anaemia treatment preferences: oral and injectable options

Of those who reported receiving ESA/EPO injections via autoinjector or syringe (n=49), 19 (39%) stated that an injection was their preferred method of receiving anaemia treatment and 18 (37%) stated tablets (orally) would be their preference for managing anaemia.

Six of seven (86%) participants who received their ESA/EPO injections from an HCP in the community at home stated that the injections are their preferred way of receiving anaemia treatment whereas 13/27 (48%) participants who injected themselves at home preferred oral tablets (figure 3).

Figure 3. Participant preferences in the modality of receiving their anaemia treatment; differences between those who self-administer EPO and those who have EPO administered in their home by an HCP in the community. In the self-administer cohort (n=27), 2 (7%) participants preferred a transfusion/IV drip, 3 (11%) had no preference and 2 (7%) did not know. Question C8 of survey (see online supplemental material). EPO, erythropoietin; HCP, healthcare professional.

Discussion

This report identified that individuals living with CKD have a high burden of intrusive symptoms, many of which align with CKD-associated anaemia, with a substantial impact on daily life. There is a potential disconnect between patient understanding and clinical management plans implemented by HCPs. Over half of the participant cohort had received ESA therapy with a substantial positive impact on both symptoms and daily living. Participants expressed a preference for both oral and injectable anaemia treatments.

Most of the study cohort had received at least one treatment for CKD-associated anaemia. Of the participants who had received treatment, over half had experience with intravenous iron, just under one-third had taken iron tablets and over half had received ESA therapy. The participants were positive about their ESA therapy experience; people felt better after receiving ESA therapy, with improvements in physical activity and exercise, activities of daily living and involvement in social activities. Effective management of CKD-associated anaemia incorporating ESA therapy has been shown to improve physical function and energy levels.¹⁷ However, for participants receiving injectable ESA therapy, doses have been missed, delayed and discarded, impacting overall adherence. Half of the participants who self-administered ESA therapy at home stated they had received formal training, and nearly one-third of them expressed they felt somewhat uncomfortable administering the treatment. In small studies of compliance to ESA therapy within the peritoneal dialysis population, non-compliance was common due to forgetting to administer, pain from injections and challenges in receiving medication.¹⁸ Compliance issues have been associated with ESA therapy administration by someone other than the patient.¹⁹ Similar challenges have been reported in non-CKD populations; barriers to implementing injectable ESA therapy in people living with sickle-cell disease include adherence, tolerability of injections and inability to self-inject.¹²

Despite most of the study cohort receiving treatment for anaemia, around a quarter reported they had not experienced anaemia and a third had not received information about anaemia. This reflects a potential disconnect between HCP and patient communications. For those who had received information, HCPs and patient websites were reported as helpful sources. These findings are corroborated by similar cross-sectional survey studies within the CKD population. Grandy et al completed an online survey of >400 people living with CKD in the USA, with and without anaemia: two-thirds of the cohort were aware of an association between CKD and anaemia; half of those with anaemia were informed about treatment options by their HCP, with iron supplementation most commonly discussed; and HCPs were the most trusted source of information but over a third of patients wanted to receive more.²⁰ Hao et al completed an online survey of 500 people living with CKD in China, with and without anaemia: most participants with a diagnosis of anaemia were aware of the association with CKD but less than half were aware of their haemoglobin levels; most patients with anaemia valued HCPs above other sources of information yet just over half of those with anaemia had received information proactively from their doctor; and dietary advice and iron supplementation were the most frequently discussed treatments.²¹

In this study cohort, there was a similar proportion of participants reporting a preference for injectable ESA therapy as there was reporting a preference for oral therapies for anaemia treatment. However, on review of how these individuals received their ESA therapy, there was a higher proportion of participants who received their injections from an HCP that preferred injectable ESA therapy compared with those who self-administered/received it from a member of their household. Findings from other studies involving predialysis and peritoneal dialysis cohorts suggest the option of avoiding regular self-administered injections appears to be a driver for preference toward oral therapies. Alexandre et al found patients are willing to accept an increase in gastrointestinal side effects to receive oral anaemia treatment over at-home subcutaneous therapy,²² and peritoneal dialysis patients preferred oral treatments to avoid self-administration and reduce storage requirements and travel.²³ In contrast, haemodialysis patients receiving intravenous ESA therapy during dialysis did not share a preference for oral treatment due to a lack of perceived convenience.²³ Lu et al found patients reported inconvenience of injectable ESA therapy storage and self-administration, whereas an oral therapy is convenient and familiar in comparison.²⁴ Thus, individuals’ CKD stage, associated treatments and personal circumstances (eg, home access to HCP support) influence treatment preferences and should be considered when making patient-centred decisions.

There are several limitations requiring careful consideration when interpreting these study findings. This is a cross-sectional study of a small number of people self-reporting their CKD diagnosis, with some specific questions receiving only a small number of responses, and no link to clinical records and objective diagnoses. The survey was designed with a focus on the experience of anaemia, ESA therapies and alternative routes of administration, with open-ended questions within these defined topics. Participation relied on access to and use of the internet, engagement with the NKF, with an associated £15 incentive for participation. Consequently, although the findings do align with the literature, they are not representative of the UK CKD population and are at risk of significant bias. In circumstances whereby the survey was completed by a caregiver on behalf of the individual living with kidney disease, demographic characteristics, their relationship with the individual (eg, partner, adult child), and whether the need for care was a direct consequence of kidney disease and/or comorbidity were not collected. Although the survey demonstrates a potential disconnect between patient understanding and clinical management plans implemented by HCPs, the HCP–patient relationship with regard to the decision-making process for the management of CKD-associated anaemia has not been explored.

Despite the limitations, the findings from this study could improve clinical practice by prompting HCPs to discuss CKD-associated anaemia with their patients and consider individual patient situations when counselling on management options, especially with the introduction of oral HIF-PH enzyme inhibitors.²⁵ Further work is needed to: understand the patient experience of CKD-anaemia from a representative CKD population with utilisation of CKD-specific patient-centred outcomes²⁶; explore the HCP experience of CKD-anaemia management and rationales for treatment preferences to aid our understanding of the decision-making process between HCPs and patients; and develop strategies to help HCPs, patients and their carers increase knowledge and promote patient-centred shared decision-making within the time constraints and pressures of the clinical service.

Conclusions

Information from HCPs about CKD-associated anaemia is highly valued by patients but inconsistently provided, with a large proportion of people living with CKD lacking key information about anaemia. Effective treatment of CKD-associated anaemia, including the administration of injectable ESA therapies, improves patient well-being and physical function. Adherence to injectable ESA therapy is challenged by storage requirements, treatment regimens, ability to and patient comfort with self-administration, and training. There is not a ‘one-size-fits-all’ approach to CKD management and a personalised approach incorporating the treatment preferences of the individual, consideration of their CKD stage, kidney replacement therapy modality (ie, haemodialysis, peritoneal dialysis or transplantation), comorbidities and home support should be explored when discussing CKD-associated anaemia treatment options.

Data availability statement

Data are available on reasonable request.