Anaemia management in people with chronic kidney disease

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Anaemia management in people with chronic kidney
disease
September, 2006
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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

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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

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how we define anaemia

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

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haemoglobin cut offs in general
populationdefining 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 gt 15 years 12.0
Males gt 15 years 13.0
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adverse effects of anaemia

• reduced oxygen utilisation
• increased cardiac output and left ventricular
  hypertrophy
• reduced cognition, concentration and libido
• reduced immune responsiveness

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stages of CKD
Stage eGFR (ml/min/1.73m2) Description
1 gt 90 Normal or increased eGFR, with other evidence of kidney damage
2 6089 Slight decrease in eGFR, with other evidence of kidney damage
3 3059 Moderate decrease in eGFR, with or without other evidence of kidney damage
4 1529 Severe decrease in eGFR, with or without other evidence of kidney damage
5 lt 15 Established renal failure
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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
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renal anaemia

• damaged kidney
• impaired production of erythropoietin
• reduced number of red blood cells
• anaemia

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other causes of anaemia in CKD

• chronic blood loss
• iron deficiency
• vitamin B12 or folate deficiency
• hypothyroidism
• chronic infection or inflammation
• hyperparathyroidism
• aluminium toxicity
• malignancy
• haemolysis
• bone marrow infiltration
• pure red cell aplasia

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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

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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

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diagnosis of anaemia of CKD in adults
eGFR lt 60ml/min/1.73m2 AND Hb 11 g/dl
Treat and repeat Hb
Yes
No
Non renal and haematinic deficiency excluded?
Consider other causes
No
Yes
No
See initial management algorithm
Patient on haemodialysis?
See sections 1.2 1.3
Yes
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initial management algorithm
Ferritin lt 500 µg/l?
Yes
No
Ferritin lt 200 µg/l?
TSAT lt 20 Or HRC gt 6
No
Yes
ESA (s.c.or i.v.)
Yes functional iron deficiency
No
Assess Hb
If Hb increase lt 1g/dl after 4 weeks, increase
ESA using dose schedule
ESA (s.c.or i.v.) and iron
Hb gt 9 g/dl
Hb lt 9 g/dl
Continue monitoring Hb and iron status
Hb lt 11 g/dl
i.v. iron
Assess Hb at 6 weeks
Hb gt 11 g/dl
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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

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Hb maintenance algorithm (assumes ESA therapy and
maintenance i.v. iron)
Measure Hb
Hb lt 11 g/dl
Hb 1112 g/dl
Hb 1215 g/dl
Hb gt 15 g/dl
? ESA dose/ frequency as per schedule unless
Hb rising by 1/g/dl/month. Check Hb as
per Schedule.
No change unless Hb rising by 1g/dl/month in
which case consider ESA dose adjustment
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
halve dose/frequency. Check Hb in 2 weeks.
If Hb is persistently low see poor response
algorithm
Ferritin lt 200 µg/l?
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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 24 weeks
• maintenance phase of ESAs every 13 months
• more actively after ESA dose adjustment

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ESA resistance

• detecting 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

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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

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implementation some overarching principles

• consider having a designated contact person(s)
  who can assume responsibility for a patients
  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

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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

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access tools online

• costing tools
• costing report
• costing template
• audit criteria
• implementation advice
• available from www.nice.org.uk/CG039

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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