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Roxadustat (FG-4592) is an oral hypoxia-inducible factor prolyl-hydroxylase inhibitor that promotes erythropoiesis through increasing endogenous erythropoietin, improving iron regulation, and reducing hepcidin.

Prior to enactment of the final investigational new drug application (IND) safety reporting rule, an attempt was made to document the effort expended at investigative sites in processing IND safety reports from sponsors and to assess the effect of these expedited reports on trial conduct. Investigators were asked to (1) prospectively document time to process IND safety reports and (2) retrospectively review safety reports from a previous 3-month period, documenting resultant actions. In this limited sample, sites spent a median of 0.25 hours per report at a median cost of US$22. Few expedited safety reports were retrospectively said to have changed study conduct or informed consent. However, a low response rate and the concentration of clinical sites in a single therapeutic area preclude generalizing these results. The authors discuss the challenges in gaining investigators’ cooperation to evaluate the impact of regulatory requirements. Better methods to facilitate this type of research will enrich the scientific basis of future clinical trial regulation and guidance.

Prior to enactment of the final investigational new drug application (IND) safety reporting rule, an attempt was made to document the effort expended at investigative sites in processing IND safety reports from sponsors and to assess the effect of these expedited reports on trial conduct. Investigators were asked to (1) prospectively document time to process IND safety reports and (2) retrospectively review safety reports from a previous 3-month period, documenting resultant actions. In this limited sample, sites spent a median of 0.25 hours per report at a median cost of US$22. Few expedited safety reports were retrospectively said to have changed study conduct or informed consent. However, a low response rate and the concentration of clinical sites in a single therapeutic area preclude generalizing these results. The authors discuss the challenges in gaining investigators’ cooperation to evaluate the impact of regulatory requirements. Better methods to facilitate this type of research will enrich the scientific basis of future clinical trial regulation and guidance.

The 2012 KDIGO (Kidney Disease: Improving Global Outcomes) Clinical Practice Guideline for Anemia in Chronic Kidney Disease provides clinicians with comprehensive evidence-based recommendations to improve patient care. In this commentary, we review these recommendations and the underlying evidence. Most recommendations are well reasoned. For some, the evidence is unclear and recommendations require some qualification. While the KDIGO guideline stresses the potential risks of intravenous iron therapy, withholding iron might have its own risks. The recommendation to avoid hemoglobin levels falling below 9 g/dL sets a lower bound of “acceptability” that may increase blood transfusion. Given the lack of research supporting the optimal transfusion strategy for end-stage renal disease patients, it is difficult to weigh the risks and benefits of red blood cell transfusion. We find a paucity of evidence that hemoglobin concentration targeted between 11 and 11.5 g/dL is associated with a safety risk. Although the evidence that erythropoiesis-stimulating agent use improves patient quality of life is poor, it is possible that the instruments used to measure quality of life may not be well attuned to the needs of chronic kidney disease or dialysis patients. Our last section focuses specifically on the recommendations to treat anemia in children.

In response to requests from patients, caregivers, and physicians for information on kidney cancer, the National Kidney Foundation (NKF) conducted a survey to assess the educational needs of the kidney cancer community. Key areas of assessment were patient and caregiver knowledge of risk factors for chronic kidney disease (CKD), including kidney cancer and nephrectomy, and of kidney-sparing surgical options.

Conflicting relationships have been described between anemia correction using erythropoiesis-stimulating agents and progression of chronic kidney disease (CKD). This study was undertaken to examine the impact of target hemoglobin level on progression of kidney disease in the CHOIR (Correction of Hemoglobin and Outcomes in Renal Insufficiency) trial.

Patients infected with human immunodeficiency virus (HIV) often progress to ESRD. In the era of highly active antiretroviral therapy, the care of these patients has become increasingly complex as survival has improved. Patients infected with HIV who also have ESRD are at risk for critical interactions between medication regimens to treat both of these conditions. Within this population, hemo- and peritoneal dialysis as well as kidney transplantation are life sustaining but present a host of obstacles related to HIV monitoring and risk of transmission, access thrombosis, infection, and rejection. Knowledge of antiretroviral regimens, drug interactions, and HIV resistance as well as the management of ESRD in the presence of HIV infection will improve the care of these unique patients.

Background Proteinuria is associated with progressive renal disease and overall mortality in HIV-infected patients; however, the prevalence and correlates of quantitative pro-teinuria in the highly active antiretroviral therapy era are unknown.Methods Spot urine protein to creatinine (P/Cr) ratios, an accepted measure of quantitative daily proteinuria, were measured annually since 2002 in participants of the AIDS Clinical Trials Group Longitudinal Linked Randomized Trials cohort. We used linear regression models with general estimating equations to identify factors associated with the abnormal P/Cr thresholds of =0.2 and =1.0.Results Of the 2,857 participants (most of whom were receiving antiretroviral therapy) analysed, 16% and 3% had P/Cr levels =0.2 and =1.0, respectively, at first measurement. P/Cr levels did not change during a median follow-up of 3 years (interquartile range 2–4). Factors associated with P/Cr=0.2 at any measurement included greater age, lower glomerular filtration rate, female sex, antiretroviral therapy prior to entry into parent randomized trial, HIV type-1 RNA level =400 copies/ ml, lower CD4+T-cell count and history of hypertension, diabetes or hepatitis C coinfection (all P<0.04). Black race and higher non-high-density lipoprotein cholesterol levels were associated with P/Cr levels =1.0, but not with P/ Cr levels =0.2. Hepatitis B coinfection and current use of adefovir, indinavir and tenofovir were not associated with either of the P/Cr thresholds.Conclusions Both HIV-1 and non-HIV-1-related factors are associated with abnormal levels of proteinuria and identify those who are at a greater risk of worse clinical outcomes. Several of these factors are differentially associated with lower and higher proteinuria thresholds.

Acute kidney injury is common in human immunodeficiency virus (HIV)-infected patients, and has been associated with increased morbidity and mortality. Before the introduction of effective antiretroviral therapy, acute kidney injury in HIV-positive patients was most commonly the result of volume depletion, septicemia, or nephrotoxic medications. Acute kidney injury remains a significant problem in the antiretroviral era, and still commonly is attributed to infection or nephrotoxic medications. Less common causes such as direct infectious insults, immune restoration inflammatory syndrome, rhabdomyolysis, and obstruction should be considered when the underlying process is not obvious. In addition to advanced HIV disease, several other patient characteristics have emerged as potential risk factors for acute kidney injury in the antiretroviral era, including older age, diabetes, pre-existing chronic kidney disease, and hepatitis co-infection or liver disease.

Recent trial data have resulted in a reevaluation of the management of anemia in chronic kidney disease, including the use of erythropoiesis-stimulating agents, intravenous iron, and novel pharmaceuticals. In this review, we evaluate the latest research on anemia management in chronic kidney disease.

Glomerular lesions that complicate patients with human immunodeficiency virus (HIV) infection include HIV-associated nephropathy, membranous glomerulopathy, and immune-complex glomerulonephritides. This case series presents 3 patients with clinically significant renal disease and positive test results for anti–glomerular basement membrane (anti-GBM) antigen. Characteristic histological findings that would suggest anti-GBM antibodies have a significant role in the pathological state of each patient’s kidney disease were absent. In addition, each patient recovered without specific treatment for anti-GBM disease. This case series suggests that anti-GBM antibodies likely are related to the B-cell expansion previously described in patients with HIV infection. We propose that clinicians interpret results of anti-GBM antibody tests carefully for patients with HIV infection, considering biopsy before empiric therapy, particularly in a clinical presentation that is atypical for Goodpasture disease.

Chronic kidney disease (CKD) is highly prevalent in patients with cardiovascular disease. We explored the associations of CKD with outcomes using combined data from two large acute coronary syndrome (ACS) trials. We also explored the associations of CKD with prescription patterns for common cardiovascular medications and the association of these prescription patterns with clinical outcomes.

Background:Hospital admissions consume a large proportion of costs for the end-stage renal disease (ESRD) program in the United States. We investigated whether a physician diagnosis of depression increases the risk for hospitalization or death in patients with ESRD receiving long-term hemodialysis (HD), independent of medical comorbidities. Methods:Centralized Veterans Affairs (VA) databases were used to identify a population-based prevalence cohort of 1,588 male patients with ESRD receiving long-term HD in VA facilities between September 1, 2000, and September 30, 2000. International Classification of Diseases, Ninth Revision, codes were used to identify comorbidities and depression diagnosis. Negative binomial regression models were used to examine the association between depression diagnosis and number of hospitalizations and cumulative hospital days in a 2-year observation period. Logistic regression models were used to investigate the association between depression diagnosis and hospitalization, death, and death or hospitalization. Results:The prevalence of physician-diagnosed depression was 14.7%. Patients with a depression diagnosis were more likely to be white and have more comorbidities. Depression diagnosis was associated with increased hospital days (rate ratio for adjusted model, 1.31; 95% confidence interval, 1.04 to 1.66) and increased number of hospitalizations (rate ratio for adjusted model, 1.30; 95% confidence interval, 1.11 to 1.52). Depression diagnosis was not statistically associated with death or the composite of death or hospitalization in adjusted models. Conclusion:Physician-diagnosed depression was associated significantly with both increased hospitalization rate and length of stay in patients with ESRD receiving outpatient HD in VA facilities, independent of demographics and comorbidities. Prospective studies should be conducted to assess whether treatment of depression will decrease hospitalization in these patients.

AbstractObjective:To examine the clinical outcomes and costs associated with Staphylococcus aureusbacteremia among hemodialysis-dependent patients.Design:Prospectively identified cohort study.Setting:A tertiary-care university medical center in North Carolina.Patients:Two hundred ten hemodialysis-dependent adults with end-stage renal disease hospitalized with S. aureusbacteremia.Results:The majority of the patients (117; 55.7%) underwent dialysis via tunneled catheters, and 29.5% (62) underwent dialysis via synthetic arteriovenous fistulas. Vascular access was the suspected source of bacteremia in 185 patients (88.1%). Complications occurred in 31.0% (65), and the overall 12-week mortality rate was 19.0% (40). The mean cost of treating S. aureusbacteremia, including readmissions and outpatient costs, was $24,034 per episode. The mean initial hospitalization cost was significantly greater for patients with complicated versus uncomplicated S. aureusbacteremia ($32,462 vs $17,011; P= .002).Conclusion:Interventions to decrease the rate of S. aureusbacteremia are needed in this high-risk, hemodialysis-dependent population (Infect Control Hosp Epidemiol2005;26:534-539).

AbstractObjective:Comorbid conditions have complicated previous analyses of the consequences of methicillin resistance for costs and outcomes of Staphylococcus aureusbacteremia. We compared costs and outcomes of methicillin resistance in patients with S. aureusbacteremia and a single chronic condition.Design, Setting, and Patients:We conducted a prospective cohort study of hemodialysis-dependent patients with end-stage renal disease and S. aureusbacteremia hospitalized between July 1996 and August 2001. We used propensity scores to reduce bias when comparing patients with methicillin-resistant (MRSA) and methicillin-susceptible (MSSA) S. aureusbacteremia. Outcome measures were resource use, direct medical costs, and clinical outcomes at 12 weeks after initial hospitalization.Results:Fifty-four patients (37.8%) had MRSA and 89 patients (62.2%) had MSSA. Compared with patients with MSSA bacteremia, patients with MRSA bacteremia were more likely to have acquired the infection while hospitalized for another condition (27.8% vs 12.4%; P= .02). To attribute all inpatient costs to S. aureusbacteremia, we limited the analysis to 105 patients admitted for suspected S. aureusbacteremia from a community setting. Adjusted costs were higher for MRSA bacteremia for the initial hospitalization ($21,251 vs $13,978; P= .012) and after 12 weeks ($25,518 vs $17,354; P= .015). At 12 weeks, patients with MRSA bacteremia were more likely to die (adjusted odds ratio, 5.4; 95% confidence interval, 1.5 to 18.7) than were patients with MSSA bacteremia.Conclusions:Community-dwelling, hemodialysis-dependent patients hospitalized with MRSA bacteremia face a higher mortality risk, longer hospital stays, and higher inpatient costs than do patients with MSSA bacteremia.

Background:The point prevalence of depression and its relationship to poor outcomes among patients with chronic kidney disease (CKD) has not been fully characterized. Methods:We performed a secondary analysis of a prospective cohort of 374 patients admitted with congestive heart failure between March 1, 1997 and June 30, 1998, to investigate the point prevalence of depression among patients with CKD and its association with mortality. The Beck Depression Inventory (BDI) was administered to all patients. Those who scored 10 or higher were administered the National Institute of Mental Health Diagnostic Interview Schedule (DIS). Logistic regression was used to examine the association between severe CKD, corresponding to a creatinine clearance less than 30 mL/min/72 kg (<0.50 mL/s/72 kg), depression, and mortality at 1 year. Results:Point prevalences of depressive symptoms by BDI and major depression by DIS were 54.8% and 21.6% if severe CKD was present and 32.8% and 13.0% if severe CKD was absent, respectively. After controlling for important clinical factors, severe CKD was associated with depressive symptoms by BDI (odds ratio, 2.89; 95% confidence interval, 1.39 to 5.99). Both depression by DIS and severe CKD were significant predictors of mortality. The increased mortality risk associated with depression did not decline with decreasing kidney function. Conclusion:Depression was more prevalent among patients with than without severe CKD and had at least as strong an association with mortality as compared with depression in patients with no or less severe CKD. The point prevalence of depression decreased when the DIS interview was used, perhaps related to the presence of somatic measures on the BDI reflecting uremia. Studies assessing the efficacy of antidepressants among patients with CKD are needed to determine whether, in addition to treating depression, pharmacotherapy impacts mortality.

Background:The treatment of hypertension in dialysis patients is prevalent and poorly characterized. β-Blockers and calcium channel blockers (CCBs) have been associated with reduced all-cause and cardiovascular mortality. This study describes the treatment of hypertension and assesses the association between mortality and class of antihypertensive medication among a cohort of dialysis patients. Methods:The US Renal Data System (USRDS) Dialysis Morbidity and Mortality Study Wave II cohort was analyzed. A total of 2,877 patients initiating hemodialysis or peritoneal dialysis in 1996 or 1997 and treated with antihypertensives were included in this analysis. Vital status was followed until November 2000. Results:Calcium channel blockers were prescribed to 70.3% of patients. Only 31.5% and 27.0% of patients with cardiovascular disease were prescribed angiotensin-converting enzyme inhibitors and β-blockers, respectively. Mono-, double-, triple-, and more than triple-therapy were reported in 48.0%, 36.1%, 13.2%, and 2.7% of the cohort, respectively. In multivariable, fully adjusted models, no individual class of antihypertensives was associated with changes in all-cause mortality. In all patients, nondihydropyridine CCBs (non-DHP CCBs) were associated with a reduced risk of cardiovascular death (hazard ratio, 0.78; 95% confidence interval, 0.62 to 0.97) and among end-stage renal disease patients with preexisting cardiovascular disease, dihydropyridine CCBs (DHP CCBs) and non-DHP CCBs were associated with reduced risk of all-cause and cardiovascular mortality. Conclusion:Calcium channel blocker use is widespread among hypertensive dialysis patients. Antihypertensive prescription patterns suggest a lack of consensus regarding treatment of hypertension. Multivariable analysis of associations between antihypertensive class and mortality reveals results of uncertain clinical significance. Hypertension treatment trials in dialysis patients should be performed to appropriately inform treatment decisions.

Interdialytic weight gain is used as a surrogate for volume expansion in haemodialysis patients and as an indicator of non-compliance. Increased weight gain is associated with both a greater mortality risk and better nutrition indices. This analysis characterizes the association between dialysis-related volume expansion and mortality in the context of its interaction with nutritional surrogates.

Many conventional cardiovascular risk factors in the general population are not as predictive in end-stage renal disease (ESRD). As absolute neutrophil count and total white blood cell (WBC) count are associated with adverse cardiovascular outcomes and all-cause mortality, this analysis was undertaken to explore the associations of WBC variables with mortality risk in ESRD.

Regional differences in haemoglobin values and process care measures were examined using data from the Centers for Medicare & Medicaid Services' End-Stage Renal Disease (ESRD) Clinical Performance Measures Project. It was posited that regional differences in haemoglobin values are consequent upon differences in components of clinical practice.

ABSTRACTThe steady-state pharmacokinetics of lamivudine were evaluated in 11 subjects with human immunodeficiency virus infection and end-stage renal disease, 9 of whom were receiving hemodialysis and 2 of whom were receiving chronic ambulatory peritoneal dialysis (CAPD). All subjects received 150 mg of lamivudine daily for at least 2 weeks prior to sampling for determination of the pharmacokinetics of lamivudine over a 24-h period on 2 consecutive days. On the first day, subjects received 150 mg of oral lamivudine and underwent dialysis (hemodialysis or CAPD). On the second day, subjects received another 150 mg of oral lamivudine but dialysis was not performed. For the subjects undergoing hemodialysis, the geometric mean predose serum lamivudine concentration was 1.14 μg/ml (95% confidence interval [CI], 0.83 to 1.58 μg/ml), the geometric mean maximum concentration in serum (Cmax) was 3.77 μg/ml (95% CI, 3.01 to 4.71 μg/ml), and the geometric mean area under the serum concentration-time curve from time zero to 24 h (AUC0-24) was 49.8 μg · h/ml (95% CI 39.1 to 63.6 μg · h/ml). Hemodialysis removed approximately 28 mg of lamivudine but had no significant effect on Cmaxor AUC0-24. In the absence of hemodialysis, the geometric mean lamivudine terminal elimination half-life was 17.2 h (95% CI, 10.5 to 28.1 h), whereas the geometric mean intradialysis half-life of lamivudine was 5.3 h (95% CI, 3.4 to 8.2 h). The pharmacokinetics of lamivudine in subjects undergoing CAPD were similar to those in subjects undergoing hemodialysis. CAPD removed 24 mg of lamivudine over a 24-h period but had no effect on Cmaxor AUC0-24. Pharmacokinetic modeling suggests that a lamivudine dose of 25 mg daily in hemodialysis subjects would provide serum exposure similar to that provided by a dose of 150 mg twice daily in patients with normal renal function.

When performing a meta‐analysis, interest often centres on finding explanations for heterogeneity in the data, rather than on producing a single summary estimate. Such exploratory analyses are frequently undertaken with published, study‐level data, using techniques of meta‐analytic regression. Our goal was to explore a real‐world example for which both published, group‐level and individual patient‐level data were available, and to compare the substantive conclusions reached by both methods. We studied the benefits of anti‐lymphocyte antibody induction therapy among renal transplant patients in five randomized trials, focusing on whether there are subgroups of patients in whom therapy might prove particularly beneficial. Allograft failure within 5 years was the endpoint studied. We used a variety of analytic approaches to the group‐level data, including weighted least‐squares regression (N=5 studies), logistic regression (N=628, the total number of subjects), and a hierarchical Bayesian approach. We fit logistic regression models to the patient‐level data. In the patient‐level analysis, we found that treatment was significantly more effective among patients with elevated (20 per cent or more) panel reactive antibodies (PRA) than among patients without elevated PRA. These patients comprise a small (about 15 per cent of patients) subgroup of patients that benefited from therapy. The group‐level analyses failed to detect this interaction. We recommend using individual patient data, when feasible, to study patient characteristics, in order to avoid the potential for ecological bias introduced by group‐level analyses. Copyright © 2002 John Wiley & Sons, Ltd.

When performing a meta-analysis, interest often centres on finding explanations for heterogeneity in the data, rather than on producing a single summary estimate. Such exploratory analyses are frequently undertaken with published, study-level data, using techniques of meta-analytic regression. Our goal was to explore a real-world example for which both published, group-level and individual patient-level data were available, and to compare the substantive conclusions reached by both methods. We studied the benefits of anti-lymphocyte antibody induction therapy among renal transplant patients in five randomized trials, focusing on whether there are subgroups of patients in whom therapy might prove particularly beneficial. Allograft failure within 5 years was the endpoint studied. We used a variety of analytic approaches to the group-level data, including weighted least-squares regression (N=5 studies), logistic regression (N=628, the total number of subjects), and a hierarchical Bayesian approach. We fit logistic regression models to the patient-level data. In the patient-level analysis, we found that treatment was significantly more effective among patients with elevated (20 per cent or more) panel reactive antibodies (PRA) than among patients without elevated PRA. These patients comprise a small (about 15 per cent of patients) subgroup of patients that benefited from therapy. The group-level analyses failed to detect this interaction. We recommend using individual patient data, when feasible, to study patient characteristics, in order to avoid the potential for ecological bias introduced by group-level analyses. Copyright © 2002 John Wiley & Sons, Ltd.

The occurrence of peripheral vascular disease (PVD) and atraumatic lower-extremity amputations is significantly greater in patients with end-stage renal disease (ESRD) than those with normal renal function. Moreover, the mortality for dialysis patients undergoing atraumatic lower-extremity amputations is far greater. Because PVD requiring amputation is an extreme form of PVD, we tested the hypothesis that mortality and intermediate outcomes for patients with ESRD undergoing lower-extremity revascularization, a less extreme form of PVD, would be equivalent to that for patients without ESRD. This is a retrospective case-control analysis of lower-extremity revascularization in patients with ESRD. Procedures in patients with ESRD were matched with procedures in non-ESRD controls for patient age, sex, race, diabetes mellitus, and hospital setting. Patient survival, graft survival, and limb salvage rates were determined using Kaplan-Meier analysis. Subjective interpretation of functional and symptomatic improvement was determined by telephone interviews with patients or relatives. Thirty-one procedures were performed on 20 patients with ESRD and 64 matched procedures were performed on 57 patients without ESRD. In the ESRD group, median patient survival was 1.72 years compared with 5.17 years for the control group (P< 0.001). Time to 50% limb loss was 1.24 years in the ESRD group and longer than 5.65 years in the control group (P< 0.001). Time to 50% graft patency loss was 0.70 years in the ESRD group and longer than 5.5 years in the control group (P< 0.05). Subjective improvement was less in patients with ESRD. Outcomes of lower-extremity revascularization in patients with ESRD are inferior to those in non-ESRD controls. The mortality rate for patients with ESRD who undergo revascularization is extremely high. Patient-related variables (eg, increased prevalence of hypertension and cardiovascular disease) and/or provider-specific factors (eg, timing of surgery in the course of PVD) may be responsible for poorer outcomes. © 2001 by the National Kidney Foundation, Inc.

Dialysis patients are the only Medicare beneficiaries prohibited from joining managed care plans. Concerns have been raised about the ability of such plans to provide the comprehensive care required by patients with this complex condition. However, more than 20,000 dialysis patients belong to such plans because they were enrolled before developing end-stage renal disease (ESRD). Disease-state management, successfully applied to patients with diabetes mellitus and congestive heart failure, Is now being used in patients with ESRD. Standardized mortality ratios (SMRs) and standardized hospitalization ratios (SHRs) were calculated for 1998 and 1999 In 1,541 patients enrolled in the RMS Disease Management program of renal disease-state management using US Renal Data System methods. SMRs were 0.643 and 0.806 for 1998 and 1999, respectively, significantly different from 1.0 for both years (P< 0.001). SHRs were 0.620 and 0.503 for 1998 and 1999, respectively, significantly different from 1.0 for both years (P< 0.001). Although additional studies are needed to define the aspects of care that are most Important for the outcomes seen, this study shows that favorable outcomes are achievable for this vulnerable patient population within a managed care setting that applies coordinated approaches to care.

The Health Care Financing Administration (HCFA) End-Stage Renal Disease (ESRD) Core Indicators Project collects clinical information on prevalent adult patients receiving in-center hemodialysis care in the United States to assess the quality of care delivered. Although hematocrit values, transferrin saturations (TSATs) and iron prescription practices have improved over the last 5 years, we sought to determine whether there are continued opportunities for improvement of this domain of care. A random sample of 7,292 adult in-center hemodialysis patients was selected for the period October through December 1996. Hematocrit values, TSATs, serum ferritin concentrations, epoetin-alfa dosing, and iron prescriptions were abstracted from 4,991 patient medical records to assess anemia management practices. The mean hematocrit for this cohort was 32.6% ± 3.5%, and 72% of patients had hematocrit values greater than 30%. Ninety-four percent of patients received epoetin alfa intravenously, with a mean weekly epoetin dose of 202.4 ± 137.2 U/kg. The mean TSAT was 27.4% ± 12.6%; 73% of patients had TSATs ≥ 20%. The mean serum ferritin concentration was 386 ± 422 ng/mL; 79% and 12% of patients had serum ferritin concentrations greater than 100 ng/mL and greater than 800 ng/mL, respectively. Nine percent of the sample had TSATs less than 20% and serum ferritin concentrations less than 100 ng/mL. Regardless of the TSAT, approximately three fourths of patients received iron; only about half received IV iron. Of the subset of patients with TSATs less than 20% and serum ferritin concentration less than 800 ng/mL, only 53% were prescribed IV iron. Although substantial improvements have been made in anemia management in hemodialysis patients over the last 5 years, significant opportunities persist to improve iron prescription practices. Am J Kidney Dis 34:s5-s11, 1999. Copyright © 1999 by National Kidney Foundation