Anaemia in CKD

Presented byDr.Chinmoy Saha

M.D Resident (Cardiology)

Contents

• Anaemia• CKD• Causes of anaemia in CKD• Use of iron to treat anemia in CKD• Use of ESAs to treat anemia in CKD• Red cell transfusion to treat anemia in CKD

Anaemia

• Anaemia refers to a state in which the level of haemoglobin in the blood is below the reference range appropriate for age and sex.

Diagnosis of anemia

• In Adults and children >15 years with CKD Hb% < 13 gm/dl in male Hb% < 12 gm/ dl in female• In Children

Age Hb %

.5-5 yr < 11.0 gm/dl

5-12 yr < 11.5 gm/dl

12-15 yr < 12.0gm/dl

Investigation

• Complete blood count (CBC) with PBF• Differential and platelet count• Absolute reticulocyte count• Serum ferritin level• Serum transferrin saturation (TSAT)• Serum vitamin B12 and folate levels

Prevalance of anemia in CKD

Monitor of Hb For CKD patients without anemia, measure Hb

concentration when clinically indicated and• at least annually in patients with CKD 3•

at least twice per year in patients with CKD 4–5ND• at least every 3 months in patients with CKD 5HD and

CKD 5PD For CKD patients with anemia not being treated with

an ESA, measure Hb concentration when clinically indicated and

• at least every 3 months in patients with CKD 3–5ND and CKD 5PD

• at least monthly in patients with CKD 5HD

CKD• CKD is defined as abnormalities of kidney

structure or function, present for >3 months, with implications for health

Stages of CKD

Erythropoiesis

Causes of anaemia in CKD

Iron Therapy for anaemia in CKD

• Targets: Ferritin > 200 microgram/L (heamodialysis) >100 microgram/L (nonheamodialysis) TSAT >20% % HRBC < 6% Reticulocyte Hb content >29 pg/cell

Recommendation

• For adult CKD patients with anemia not on iron or ESA therapy a trial of IV iron (or in CKD ND patients alternatively a 1–3 month trial of oral iron therapy) if

an increase in Hb concentration without starting ESA treatment is desired and

TSAT is less equal 30% and ferritin is less equal 500 ng/ml

• For adult CKD patients on ESA therapy who are not receiving iron supplementations a trial of IV iron (or in CKD ND patients alternatively a 1–3 month trial of oral iron therapy) if :

• an increase in Hb concentration or a decrease in ESA dose is desired and

• TSAT is less equal 30% and ferritin is less equal 500 ng/ml

Monitor

• Evaluate iron status (TSAT and ferritin) at least every 3 months during ESA therapy,

including the decision to start or continue iron therapy.

• Test iron status (TSAT and ferritin) more frequently when

initiating or increasing ESA dose, when blood loss, monitoring response after of IV iron,

where iron stores become depleted.

Preparation

• Preparation Oral iron therapy IV iron therapy• Adverse Reactions Anaphylaxis Hypotension Nausea,vomiting,pruritus,dizziness

EPO

• EPO is a 165 amino acid secreted glycoprotein that is required for erythrocyte maturation

• It is produced by peritubular interstitial fibroblast

• If GFR is normal,EPO level is inversely propotional to Hb.

EAS

Types

ESA Half Life Initial dosing

Epoetin 4-8 hr 80-120 u/kg in 3 divided dose

Epoetin 4-12 hr 80-120 u/kg in 3 divided dose

Darbepoetin 21-25hr .45microgram/kg weekly

Methoxy Polyethylene glycol

130 hr .6microgram/kg fortnightly,then monthly

ESA therapy

• Address all correctable causes of anemia (including iron deficiency and inflammatory states) prior to initiation of ESA therapy.

• The objectives of initial EAS therapy is a rate to increase Hb 1-2 g/dl per month.

Frequency of monitoring

During the initiation phase of ESA therapy,• measure Hb concentration at least monthly • For CKD ND patients, during the maintenance phase of ESA therapy measure Hb concentration

at least every 3 months. (Not Graded)• For CKD 5D patients, during the maintenance phase of ESA therapy measure Hb concentration

at least monthly. (Not Graded)

KDIGO Recommendation• For adult CKD ND patients with Hb concentration >10.0 g/dl ESA

therapy not to be initiated.

• For adult CKD ND patients with Hb concentration <10.0 g/dl to initiate ESA therapy based on

• the rate of fall of Hb concentration,• prior response to iron therapy,• the risk of needing a transfusion,• the risks related to ESA therapy and• the presence of symptoms attributable to anemia.

• For adult CKD 5D patients, ESA therapy is to be used when the hemoglobin is between 9.0–10.0 g/ dl (90–100 g/l).

Red cell transfusion in CKD

Indication of Blood transfusion• When rapid correction of anemia is required to

stabilize the patient’s condition e.g.,acute hemorrhage

• When rapid pre-operative Hb correction is required• When symptoms and signs related to anemia are present in patients in whom ESA therapy is

ineffective.• When symptoms and signs related to anemia are present in patients in whom the risks of ESA therapy may outweight the benefits

Alogorithm

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