renal anemia guidelines

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


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


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


Burden of anemia in CKD


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.


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


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.


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


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


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


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


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


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%


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.


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


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


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


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


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


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


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.


Contraindications to ESA therapy• Uncontrolled hypertension• Uncontrolled seizures• Hb>15g/dl (requires at least dose

reduction, see algorithm in section)


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


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


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


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&sectionid=00014

5- Sheffield Kidney Institute Local renal guidelines for management of anemia in CKD6-KDOQI guidelines 20137-Nice guidelines

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