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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