Barriers and Facilitators to Vadadustat Use for Managing Anemia in Adult Patients Undergoing Dialysis: A Qualitative Evidence Synthesis

Anemia in patients on maintenance dialysis is routinely managed with erythropoiesis-stimulating agents (ESAs) and iron supplementation. Vadadustat, an oral hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI) that stimulates endogenous erythropoietin and improves iron metabolism, presents a novel therapeutic alternative. Following its March 2024 U.S. Food and Drug Administration approval for adult patients on dialysis for at least three months, the clinical adoption of vadadustat continues to face significant implementation hurdles despite demonstrating non-inferiority to ESAs. In this study, we sought to identify and characterize the barriers and facilitators influencing the real-world integration of vadadustat for managing symptomatic anemia in adults undergoing dialysis for chronic kidney disease. We conducted a qualitative evidence synthesis, analyzing data from clinical trials, regulatory documents, and the nephrology literature. Our analysis identified 59 distinct barriers and 51 facilitators across healthcare systems, clinical practice, patient, and pharmacoeconomic domains. Prominent barriers include cardiovascular safety concerns, cost and reimbursement challenges, established ESA infrastructure, and prescriber unfamiliarity with the HIF-PHI drug class. Conversely, key facilitators comprise the convenience of oral administration, improved iron utilization, potential to overcome ESA hyporesponsiveness, and individual patient preference for oral therapy. Based on these findings, we propose a synthesis-derived multidisciplinary implementation framework built on six core principles: evidence-based patient selection, risk stratification and monitoring, shared decision-making, gradual transition strategies, interdisciplinary team engagement, and outcomes-based evaluation. Understanding these implementation determinants is crucial for optimizing anemia management in the dialysis population, ensuring that appropriate patient subgroups can benefit from vadadustat administration while balancing safety and cost-effectiveness.