Anaemia management in people with chronic kidney disease

September, 2006

changing clinical practice

NICE guidelines are based on the best available evidence

the Department of Health asks NHS organisations to work towards implementing guidelines

compliance will be monitored by the Healthcare Commission

who should read the guidance?

all healthcare professionals

people with anaemia of CKD and their families and carers

patient support groups

commissioning organisations

service providers

how we define anaemia

a state in which the quality and/or quantity of circulating red blood cells is below normal

haemoglobin cut offs in general population

defining anaemia in people living at sea level Age or gender group Haemoglobin below

(g/dl)

Children

6 months to 5 years 11.0

5 to 11 years 11.5

12 to 14 years 12.0

Non-pregnant females > 15 years

12.0

Males > 15 years 13.0

adverse effects of anaemia

reduced oxygen utilisation

increased cardiac output and left ventricular hypertrophy

reduced cognition, concentration and libido

reduced immune responsiveness

stages of CKDStage eGFR

(ml/min/1.73m2)Description

1 > 90 Normal or increased eGFR, with other evidence of kidney damage

2 60–89 Slight decrease in eGFR, with other evidence of kidney damage

3 30–59 Moderate decrease in eGFR, with or without other evidence of kidney damage

4 15–29 Severe decrease in eGFR, with or without other evidence of kidney damage

5 < 15 Established renal failure

how prevalent is anaemia of CKD?NHANES III data

eGFR (ml/min/1.73m2

Median Hb in men (g/dl)

Median Hb in women (g/dl)

Prevalence of anaemia

60 14.9 13.5 1%

30 13.8 12.2 9%

15 12.0 10.3 33%

renal anaemia

damaged kidney

impaired production of erythropoietin

reduced number of red blood cells

anaemia

other causes of anaemia in CKD

chronic blood lossiron deficiency

vitamin B12 or folate deficiencyhypothyroidismchronic infection or inflammationhyperparathyroidismaluminium toxicitymalignancyhaemolysisbone marrow infiltrationpure red cell aplasia

key goals in managing anaemia of CKD

• increase exercise capacity

• improve cognitive function

• regulate and/or prevent left ventricular hypertrophy

• prevent progression of renal disease

• reduce risk of hospitalisation

• decrease mortality

what the recommendations cover

diagnosis of anaemia of CKD

management of anaemia of CKD

assessment and optimisation of erythropoiesis

maintaining stable haemoglobin

monitoring of ACKD treatment

diagnosis of anaemia of CKD in adults

eGFR < 60ml/min/1.73m2

AND Hb ≤ 11 g/dl

No

Consider other causes

Yes

Non renal and haematinic

deficiency excluded?

No

Treat and repeat Hb

Yes

Patient on haemodialysis?

No

See sections 1.2 & 1.3

Yes

See initial management

algorithm

initial management algorithm

Ferritin < 500 µg/l? NoYes

Ferritin < 200 µg/l?

Yes NoTSAT < 20% Or

%HRC > 6%

NoYes – functional iron deficiency

Assess Hb

ESA (s.c.or i.v.)

Hb > 9 g/dl Hb < 9 g/dl

i.v. iron

ESA (s.c.or i.v.)

and iron

Assess Hb at 6 weeks

Hb < 11 g/dl

Hb > 11 g/dl

Continuemonitoring Hb and iron status

If Hb increase < 1g/dl after 4 weeks, increase

ESA using dose schedule

assess and optimise erythropoiesis

iron supplements should be given to maintain serum ferritin levels

ESA therapy is appropriate in iron-replete patients where existing comorbidities or prognosis do not negate its effect

benefits of ESA therapy include improved quality of life and physical functioning

there is no evidence to distinguish between ESAs in terms of efficacy

Hb maintenance algorithm (assumes ESA therapy and maintenance i.v. iron)

Measure Hb

Hb < 11 g/dl Hb 11–12 g/dl Hb 12–15 g/dl Hb > 15 g/dl

↑ ESA dose/frequency as per schedule

unless Hb rising by

1/g/dl/month. Check Hb

as perSchedule.

No changeunless Hbrising by

1g/dl/monthin which case

considerESA doseadjustment

Consider stopping i.v.iron. ↓ ESA

dose/frequency as per schedule

unless Hb falling by more

than 1g/dl/month. Check Hb as per schedule.

Stop i.v. iron.Consider stopping

ESA or halvedose/frequency.

Check Hb in 2 weeks.

If Hb ispersistently low

see poor response algorithm

Ferritin < 200 µg/l?

monitor treatment

iron status:

• not earlier than 1 week after i.v. iron

• routinely at intervals of between 4 weeks and 3 months

haemoglobin:

• induction phase of ESAs every 2–4 weeks

• maintenance phase of ESAs every 1–3 months

• more actively after ESA dose adjustment

ESA resistancedetecting ESA resistance

• target Hb levels not being reached despite appropriate treatment

• continuing need for high doses to maintain Hb

other possible causes

• exclude other causes of anaemia

• check medicine concordance

• algorithm for poor response to ESAs

ESA resistance

• aluminium toxicity – desferrioxamine test when aluminium toxicity suspected

• pure red cell aplasia (PRCA) – ESA-induced PRCA managed in accordance with best practice

implementation – some overarching principles

consider all age groups for anaemia management where appropriate

work across primary and secondary care to develop and share local protocols based on algorithms. Have clear pathways for specialist advice

develop training programmes to support patients and their carers

implementation – some overarching principles

consider having a ‘designated’ contact person(s) who can assume responsibility for a patient’s anaemia management

review local tendering arrangements and provision of ESAs and intravenous therapy in light of recommendations

raise awareness with relevant groups about the aims of ESA therapy

Put systems in place to review management of ESA therapy with patients after an agreed interval

costs and savings

ESAs treatment with ESAs should be offered to patients with anaemia of CKD who are likely to benefit in terms of quality of life and physical function.

determinant for treatment – age age alone should not be a determinant for the treatment of CKD

access tools online

costing tools

•costing report•costing template

audit criteria

implementation advice

available from: www.nice.org.uk/CG039

access the guideline online

quick reference guide – a summary www.nice.org.uk/CG039quickrefguide

NICE guideline – all of the recommendations www.nice.org.uk/CG039niceguideline

full guideline – all of the evidence and rationale www.nice.org.uk/CG039fullguideline

information for the public – a plain English version www.nice.org.uk/CG039publicinfo