Post on 14-Jan-2017
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Management of Anemia in Chronic Kidney Disease Patients
Rebeen Saeed MMedSci Nephrology (Uo-Sheffield-UK)Board Candidate of Internal Medicine
General University Teaching Hospital of Slemani-Department of Medicine
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Historical background
• Richard Bright (1836): first observed that anemia was a complication of renal failure.
• Robert Christison: further described renal anemia.
• Miyake (1977): purified and identified erythropoietin.
• Eschbach (Dec 2, 1985): first human use of EPO
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Burden of anemia in CKD• According to the NHANES III data, the drop in Hb was
significant in males whose GFR dropped below 75ml/min and females whose GFR dropped below 45ml/min
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Burden of anemia in CKD
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Effects of anemia(mortality)• Generation of hypoxia due to anemia is poorly
tolerated in patients with preexisting cardiac and vascular diseases. Compensatory mechanisms leads to development of LVH.
• Observational studies do show an increase in mortality in patients with CKD but not direct casualty.
• Interventional studies (DOPPS) show that for an increase of 1g/dL of Hb results in 4% decline in mortality.
• Also, Medicare data show that CKD=100% and CKD+Anemia=270% in 2-yr mortality risk.
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
EFFECTS of anemia on CV health
• CV disease related mortality is 15 times more in patients with CKD.
• 50% of deaths in patients with CKD are due to CV disease.
• LVH is the most common abnormality seen in patients with CKD and there is a strong correlation between anemia and LVH.
• Tissue hypoxia due to anemia is the principal stimuli triggering the compensatory changes that stresses the CV system
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Other effects of anemia in CKD
• Acceleration of progression of kidney disease by oxygen deprivation.
• Increased risk of bacteremia (11% increased risk for every 1g/dl fall in Hb)
• Detrimental effects on brain and cognitive functions.
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Renal Anemia Guidelines• Anaemia is a common feature of chronic kidney disease.Renal anaemia results in • increased morbidity• admission rates • diminished quality of life• Renal anaemia can be successfully treated with
Parenteral iron and Erythropoiesis Stimulating Agents (ESAs).
• NICE guidelines recommend a target haemoglobin concentration of 11-12g/dl
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
This protocol sets out appropriate schedules for the management and monitoring of renal anaemia in the General University
Teaching Hospital of Slemani.1. An appropriate schedule for blood testing and monitoring
2. Target blood levels for iron parameters and haemoglobin
3. A safe algorithm for parenteral iron dosage and
administration
4. A safe algorithm for ESA dosage and administration
5. Safety issues
6. Instructions on documentation of prescribing and
administration
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Anaemia affects many patients with chronic kidney disease (CKD) stage 4 or 5 and about
1% with CKD stage 3
All patients with a Hb of less than 11g/dl should be considered for iron and ESA treatment. Two main factors cause renal anaemia
- Absolute or functional iron deficiency
-Reduced production of the hormone epoetin (EPO) by the kidney
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
InvestigationsAll patients with CKD should have the following blood investigations prior to commencing anaemia treatments
FBC
Haematinics-Iron Profile (serum iron and total iron binding capacity)-Serum Ferritin-B12 and Folate
- CRP (C reactive protein – to assess inflammation)
- PTH – to assess parathyroid function
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
A FBC and iron studies to be measured at least 3 monthly for all CKD 4/5 patients.
In practice, this will be at every clinic visit for non-HD patients.
Hospital HD patients are tested monthly by default.
Ferritin and iron profile measurements should be at least one week after the last dose of IV iron sucrose.
All testing should be pre-HD.
After initiation of ESA, monthly FBC monitoring is required until a stable Hb 11-12g/dl is achieved.
Thereafter three-monthly monitoring is acceptable for non-HD patients.
Schedule for the tests
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Assessing Iron status •Absolute iron deficiency – ferritin<100ug/l, TSAT<20%
Assessing Iron status •Functional iron deficiency – ferritin>100ug/l, TSAT<20%
Assessing Iron status
•TSAT is defined as (serum iron/total iron binding capacity) x 100%
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Absolute iron deficiency should be treated, except in patients who become polycythaemic when iron replete. Functional iron deficiency in non-HD patients who are not on ESAs should be treated only the Hb is less than 11g/dl.
CKD 4/5 patients on ESAs or with an Hb<11g/dl should be given iron supplements to keep their:
Serum ferritin between 200 and 500 mcg/l in HD patients
Serum ferritin between 100 and 500 mcg/l in non-HD patients
The TSAT level above 20%
Iron supplements should be discontinued when the ferritin is greater than 800 mcg/l irrespective of the TSAT.
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Thresholds and targets for treatment
• As a general principle, intravenous iron therapy should be synchronised with planned outpatient visits unless dictated otherwise by clinical urgency. Exceptions to this rule will comprise less than 25% of doses but would include patients with:
- Severe anaemia (Hb less than 9g/dl).- Severe symptoms where an emergency admission may
be prevented (e.g. decompensated heart failure)- Planned interval to next OP of greater than 3 months
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Measure HB
HB< 11 g/dl HB 11-12 g/dl HB 12-15 g/dl HB >15 g/dl
Increase dose/Frequency according to schedule unless HB rising by> 1gm/dl/month Check Hb according to schedule
No change
unless HB rising by> 1gm/dl/month Check Hb according to schedule
Consider stopping IV iron. Decrease dose/Frequency according to schedule unless HB falling by> 1gm/dl/month. Check Hb according to schedule
Stop IV iron, consider stopping ESA or halve dose/frequency Check Hb in 2 weeks
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Haemodialysis (HD) Patients :Monitored by monthly pre-HD FBC and iron studies HHD Patients 4-6 weekly blood tests
Iron sucrose regime TSAT Ferritin
100mg weekly on HD ANY 1-200
100mg weekly on HD <20% 201-500
100mg fortnightly on HD >20% 201-500
100mg monthly on HD <20% 501-800
Withhold >20% 501-800
Withhold Any >800
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Non-HD patientsIron sucrose is given intermittently in cycles of 3-5 doses as required to maintain the targets specified, (monitored at least 3 monthly). A single dose of
iron sucrose may be given to patients with a serum ferritin <500 in the absence of a TSAT measurement but the TSAT must be measured prior to subsequent doses.
Iron sucrose regime TSAT Ferritin
5 doses 200mg over 6-10 weeks ANY <100
3 doses 200mg over 3-6 weeks <20% 100-500
Withhold >20% 100-500
3 doses 200mg over 3-6 weeks <20% 501-800
Withhold >20% 501-800
Withhold Any >800
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Recently the Ferinject is used for Non HD patients in the following method
AdministrationTime15min infusion200mls per hour
Amount ofsterile 0.9%sodiumchloride fordilution
Ferinject®(ferricCarboxymaltose)
TSAT Ferritin
15 minutes 30mls 1000mg**(in 20mls)
ANY <100
15 minutes 30mls 1000mg (in20mls)
<20% 100-500
15 minutes 40mls 500mgs(in 10mls)
>20% 100-500
15 minutes 40mls 500mg(in 10mls)
<20% 501-800
Withhold Withhold >20% 501-800
Withhold Withhold Any >800
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
For (Epoitin Beta) NeoRecormon it's single dose weekly as stated bellow, but for Epoitin Alpha(Epogen, Procrit, Eprex, erythropoietin) (which is available in
Kurdistan) it's Recommended starting dose: 50-100 Units/kg IV/SC 3 times/week dose or single dose weekly .adjustment schedule
decrease weekly dose(Unit) IIncrease weekly dose(Unit) Current Weekly dose(Unit)
suspend 3000 2000
2000 4000 3000
3000 5000 4000
4000 6000 5000
5000 8000 6000
6000 10000 8000
8000 12000 10000
10000 16000 12000
12000 Seek Advice 16000
Seek Advice Seek Advice >16000
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Complications of ESA therapy• Hypertension• Seizures• HD vascular access thrombosis• The risks are in proportion to the absolute
Hb and the rate of rise of Hb. 1g/dl/month is believed to be the optimum rate of rise.
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Contraindications to ESA therapy• Uncontrolled hypertension• Uncontrolled seizures• Hb>15g/dl (requires at least dose
reduction, see algorithm in section)
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Blood pressure monitoring
• All patients on ESA therapy (initiation and maintenance) require blood pressure measurement prior to administration
• ESA should not be given if the diastolic blood pressure consistently exceeds 100mmHg or the systolic consistently exceeds 170mmHg
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Failure to respond to ESA therapy• ESA resistance (defined here as Hb<11g/dl
after correction of functional iron deficiency and 8 weeks therapy with maximum dose of Epirex and (NeoRecormon) should be brought to the attention of the relevant consultant nephrologist
• haematinic deficiency, chronic inflammation/infection, hyperparathyroidism, under-dialysis, haemolysis, aluminium toxicity and Pure Red Cell Aplasia
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Professor Meguid El Nahas, PhD, FRCPProfessor of Nephrology University of Sheffield
Director of Global Kidney Academy
Dr. William McKane PhD, FRCP Consultant Nephrologist and Director of postgraduate education at Sheffield Kidney Institute in Northern General Hospital, UK
I consulted Those two Experts in Sheffield Kidney Institute for writing this Guideline
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
References1. CG114 Anaemia management in chronic kidney disease. NICE guideline, February
2011 http://guidance.nice.org.uk/CG1142. Epoetin beta (a recombinant human erythropoietin) medicines. The electronic
Medicines Compendium (eMC) March 2010 http://www.medicines.org.uk/EMC/medicine/1717
3. Summary of Product Characteristics, Ferinject®, last updated 11/08/20094. ESA Risks, Benefits Highlighted by TREAT Study in Pre-Dialysis Patients. NAAC Review
Published: November 19, 2009 http://www.anemia.org/professionals/reviews/content.php?contentid=000468§ionid=00014
5- Sheffield Kidney Institute Local renal guidelines for management of anemia in CKD6-KDOQI guidelines 20137-Nice guidelines
•
General University Teaching Hospital of Slemani-Department of Medicine Renal Anemia Guidelines
Thank You
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