Anemia in ckd

anemia in CKD

1. DR RAMESH KRISHNAN DNB INTERNAL MEDICINE

2. Contents Definition of CKD Stages of CKD Definition of anemia in CKD . Causes of anemia in CKD. Evaluation of patients Iron therapy. ESA

3. Definition of Chronic Kidney Disease Kidney damage for  3 months with or without decreased GFR, manifest by either: Pathological abnormalities; or Markers of kidney damage, including abnormalities in the composition of the blood or urine, or abnormalities in imaging tests. 1. GFR <60 mL/min/1.73m 2 for  3 months

4. Stages of CKD Stage GFR (ml/min/1.73 m 2 ) Description 1 > 90 Normal or increased GFR, with other evidence of kidney damage 2 60–89 Slight decrease in GFR, with other evidence of kidney damage 3a 45–59 Moderate decrease in GFR, with or without other evidence of kidney damage 3b 30–44 4 15–29 Severe decrease in GFR, with or without other evidence of kidney damage 5 < 15 Established renal failure Diagnosis should be on the basis of evidence of CKD for ≥ 3 months

5. Defining anaemia in CKD Age or gender group Hb below (g/dl) Children 6 months to 5 years 11.0 5 to 11 years 11.5 12 to 14 years 12.0 Women > 15 years (non-pregnant) 12.0 Men > 15 years 13.0 Hb cut-off levels – World Health Organization KDIGO 2011

6. WHAT CAUSES ANEMIA IN CHRONIC KIDNEY DISEASE? Relative Erythropoietin (EPO) deficiency Iron deficiency Blood loss Shortened red cell life span Vitamin deficiencies The “uremic milieu” /Bone marrow suppression Inflammation Hyperparathyroidism Unfortunately, we know little about the relative contributions of the different factors and conditions in the early stages of chronic kidney disease.

7. Relative EPO deficiency Erythropoietin regulates Erythropoiesis Glycosylated polypeptide 90% produced in the peritubular interstitial Fibroblasts like cells of kideny ,10 % in the liver Produced in response to low oxygen tension in the tissues of kidneys CAUSES ANEMIA IN CKD

8. IDA in CKD Blood loss from GI tract In HD patients : Repeated Blood Loss ; retention of Blood in Dialyzer and blood lines. Frequent Blood Sampling for Ix Loss from Surgical Procedures ( vascular access) Interference with absorption due to Meds ( Gastric acid inhibitors ,Phosphate Binders ) Reduced absorption due to inflammation CAUSES ANEMIA IN CKD

9. Blood loss Risk of blood loss due to platelet dysfunction. The main cause of blood loss is dialysis, especially hemodialysis, and the loss results in absolute iron deficiency. Hemodialysis patients may lose 3 to 5 g of iron per year. CAUSES ANEMIA IN CKD

10. Shortened red blood cell life span The life span of red cells is reduced by approximately one third in hemodialysis patients CAUSES ANEMIA IN CKD

11. “uremic milieu” The “uremic milieu” is a term that is overused in attempts to explain the multiple organ dysfunction of chronic kidney disease . For example, “uremic” serum has been shown to inhibit primary bone marrow cultures of early erythroid cell lines. CAUSES ANEMIA IN CKD

12. Diagnosis and evaluation of anemia in CKD Age or gender group Hb below (g/dl) Children 6 months to 5 years 11.0 5 to 11 years 11.5 12 to 14 years 12.0 Women > 15 years (non-pregnant) 12.0 Men > 15 years 13.0 When estimated glomerular filtration rate ( eGFR ) of less than 60 ml/min/1.73m2 should trigger investigation into whether anaemia is due to CKD

13. Use of iron to treat anemia in CKD Iron supplementation is widely used in CKD patients: To treat iron deficiency Prevent its development in ESA treated patients Raise Hb levels in the presence or absence of ESA treatment Reduce ESA doses in patients receiving ESA treatment.

14. When to start iron therapy? For adult CKD patients with anemia not on iron or ESA therapy , a trial of IV iron (or in CKD ND patients alternatively a 1–3 month trial of oral iron therapy) if: an increase in Hb concentration without starting ESA treatment is desired and TSAT is <30% and ferritin is <500 ng/ml (<500 mg/l)

15. For adult CKD patients on ESA therapy who are not receiving iron supplementation , a trial of IV iron(or in CKD ND patients alternatively a 1–3 month trial of oral iron therapy) if : an increase in Hb concentration or a decrease in ESA dose is desired and TSAT is <30% and ferritin is <500 ng/ml (<500 mg/l)

16. At increasingly higher ferritin levels, there is some evidence to indicate that hepatic deposition of iron increases Routine use of iron supplementation in patients with TSAT >30% or serum ferritin >500 ng/ml (>500mg/l) is not recommended

17. Monitoring therapy

18. ESA Therapy

19. When to start ESA ? CKD 5D ESA therapy should be initiated when the Hb is between 9.0–10.0 g/dL Address all correctable causes of anemia prior to initiation of ESA therapy . CKD ND Hb > 10g/dL - ESA not to be initiated Hb < 10g/dL - initiation of ESA therapy be individualized

20. H O W? E p o e t i n - a l fa or epoetin-beta 20 -50 IU/kg three times a week. (SC) or IV D a r be p o e ti n - alfa 0.45 mcg/kg once weekly by subcutaneous (SC) or IV 0.75 mcg/kg once every 2 weeks SC CERA 0.6 mg/kg once every 2 weeks SC - CKD ND IV - CKD 5D 1.2 mg/kg once every 4 weeks by SC - CKD ND For CKD 5HD patients and those on hemofiltration or hemodiafiltration therapy, either IV or SC administration of ESA. For CKD ND and CKD 5PD patients, subcutaneous administration of ESA. ESA Therapy

21. TARGET HB LEVEL: Objective of initial ESA therapy is a rate of increase in (Hb) of 1.0 to 2.0 g/dl (10 to 20 g/l) per month Rise in Hb of > 2.0 g/dl (20 g/l) over a 4-week period should be avoided Target Hb ; not to exceed > 11.5g/dL HB initially monitored weekly , dose adjustment made every 4 weekly. Once stable HB achieved , monitor 4 weekly to 3 monthly , or in between any intercurrent illness or symptomatic . ESA Therapy

22. DOSE MODIFICATION If HB level increases by >1gm%/2wks, then reduce dose of EPO by 25%. If HB level not increases by >1gm%/ mnth , then increase dose of EPO by 25%. ESA Therapy

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