[11] Anaemia is a common problem in Taiwanese CKD patients. Published data indicate that 58.8% of patients with stage 4 CKD in Taiwan are anaemic, and the prevalence selleck compound of anaemia increases to 92.5% in patients reaching stage 5 CKD.[10] On 1 March 1995, Taiwan’s government launched the national health insurance (NHI) system, which ensures the right to healthcare for all residents and provides free access and total coverage of medical expenses for renal replacement therapy.

At the same time, the NHI implemented a fully bundled payment system for HD expenses including the actual cost of dialysis, the cost of dialysis-related laboratory tests, and the cost of using calcium-containing phosphate binders, active vitamin D, and ESAs. In order to promote

the use of peritoneal dialysis (PD), the NHI executed a partially bundled system in the PD treatment payment in which the reimbursement for ESAs was not included. Because almost everyone with ESRD in Taiwan is entitled to the NHI, the incentive to select healthier patients is greatly reduced in the case of dialysis. Erythropoiesis-stimulating agents soon became one of the largest drug expenditures in the NHI program of Taiwan. In 1996, the NHI applied more restrictive reimbursement criteria for ESA use targeting to a lower haematocrit in patients with CKD. ESAs are to be initiated when non-dialysis CKD patients have a serum creatinine >6 mg/dL Thiamet G and a haematocrit <28%, and CH5424802 solubility dmso to maintain a haematocrit level not exceeding 30%. The maximal dose of epoetin-α or β was capped at 5000 U per week, as opposed to 9000 units per week in Japan or 400 000 units per month in the United States. The target haematocrit range and dose limitation for ESAs were the same for dialysis-dependent

CKD patients. We analyzed data from the Taiwan Renal Registry Data System (TWRDS) to examine the national trends of anaemia management in prevalent dialysis patients from 1995 to 2012. The proportion of HD patients with haematocrit <28% declined from 49% to 11%. By contrast, the proportion of those with haematocrit ≥32% rose from 16% to 32% (Fig. 1a). In 1995, mean haemoglobin was 8.9 g/dL (haematocrit 26.8%) in HD patients (Fig. 1b). Mean haemoglobin increased to 10.1 g/dL (haematocrit 30.4%) in 2004, compared with 10.4 g/dL in Japan and 11.7 g/dL in the United States, and rose steadily to 10.5 g/dL (haematocrit 31.6%) in 2012, similar to that in the United States and Japan from the DOPPS study.[12-14] The proportion of HD patients prescribed ESA remained stable at around 80%, compared with 89% in the United States and 91% in Japan. The year trend in haematocrit distribution for PD patients was similar to HD patients (Fig. 1c). However, the proportion of PD patients prescribed ESAs rose from 74.0% in 2006 to 86.2% in 2012 (Fig. 1d).