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Role of Anaemia – from CRS to CRAS CRAS definition and epidemiology.

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Presentation on theme: "Role of Anaemia – from CRS to CRAS CRAS definition and epidemiology."— Presentation transcript:

1 Role of Anaemia – from CRS to CRAS CRAS definition and epidemiology

2 The First Definition of CRAS Silverberg proposed the term Cardio-Renal Anaemia Syndrome (CRAS) 10 years ago to reflect that there is an interaction between renal failure, heart failure and anaemia Silverberg D et al. Eur J Heart Fail 2002;4(6):681–686 Anaemia Heart failure Renal failure

3 The Definition of CRAS Differs Depending on your Viewpoint (1) Nephrologists CKD Any degree of anaemia Any degree of heart failure CKDSevere anaemia Severe heart failure Renal failureSevere anaemiaCardiovascular events Renal failureAnaemia Cardiovascular disease CKDAnaemiaCHF

4 The Definition of CRAS Differs Depending on your Viewpoint (2) Cardiologists CHF Any degree of anaemia Any degree of renal insufficiency CHFSevere anaemiaRenal failure Cardiovascular disease Severe anaemiaRenal failure Cardiovascular disease AnaemiaRenal insufficiency CHFAnaemiaCKD

5 A Definition of CRAS for 2010 CRAS is a pathophysiological process involving the progressive deterioration of heart and kidney function linked with worsening anaemia – CRAS is a vicious cycle where worsening of one factor negatively impacts on the other two conditions and itself, resulting in progressive deterioration CRAS is a combination of heart failure, kidney failure and anaemia What defines the above factors? Any degree of heart failure Any degree of anaemia Any degree of kidney failure

6 The Prevalence of CRAS is Dependant upon your Definition of CKD, CHF and of Anaemia CHFCKD Anaemia Anaemia + CKD Anaemia + CHF CRAS CHF + CKD

7 A total of 9,971 patients had a value for Hb reported that was 11 g/dL in 18% of men and 23% of women Cleland JG et al. Eur Heart J 2003;24:442–463 N=5249 men 33% with Hb <12 g/dL Number of patients Hb (g/dL) –4.4 5–5.4 6–6.4 7–7.4 8–8.49–9.4 10– – –12.413– – –15.416– –17.418–18.419– –20.4 Hb levels in the EuroHeart Failure Survey Programme

8 CRAS in US and European HF Surveys Galvao M et al. J Card Fail 2006;12:100–107; Nieminen MS et al. Eur J Heart Fail 2008;10:140– ADHERE 105,000 patientsEuroHF Survey II Renal failureAnaemia Patients (%)

9 Prevalence Data for CRAS are Varied Anaemia is common in patients with heart failure (HF) –prevalence ranges from 4–55% 1 In patients with CHF NYHA functional class IV, the prevalence of anaemia when defined as <12g/dL and 11g/dL was 79.1% 3 and 14.4%, respectively 4 The prevalence of renal impairment plus anaemia (11g/dL) in New York heart association (NYHA) functional class IV HF patients is 6.3% 4 The prevalence of chronic renal insufficiency (CRI) in new onset HF patients is 8.8% 2 and the prevalence of renal insufficiency in acutely decompensated HF patients is 30% 5 The prevalence of CHF in endstage renal disease is 63.7% 6 1. Lang C & Mancini D. Heart 2007;93:665–671; 2. Ezekowitz J et al. Circulation 2003;107:223–225; 3. Silverberg D et al. J Am Coll Cardiol 2000;35:1737–1744; 4. Cromie N et al. Heart 2002;87:377–378; 5. Fonarow G et al. JAMA 2005;293:572–580; 6. Avorn J et al. Arch Intern Med 2002;162:2002–2006

10 New-onset HF Patients with both CKD and Anaemia Population-based cohort of 12,065 patients with new-onset CHF – Database analysis from 138 acute- care Canadian hospitals – April 1993–March 2001 – Analysis of prevalence and cause of anaemia Adapted from Ezekowitz J et al. Circulation 2003;107:223–225 14% 3% 6% 77% CHF + anaemia alone (n=1,696) CHF + anaemia + CKD (n=387) CHF + CKD alone (n=674) CHF alone (n=9,308)

11 HF, CKD and Anaemia Occur Frequently in the Same Patient Prospective, single-centre, observational study 2 – 955 consecutive patients with HF (LVEF <45%) – Median follow-up 531 days – Investigation of the presence of anaemia, and its cause Adapted from de Silva R et al. Am J Cardiol 2006;98:391–398 CHF + anaemia* alone (n=94) CHF + anaemia* + CKD** (n=211) CHF + CKD** alone (n=307) CHF alone (n=343) LVEF, left ventricular ejection fraction *Hb <12 g/dL in women, <13 g/dL in men; **eGFR <60 mL/min/1.73 m 2 10% 22% 32% 36% CHF + anaemia* alone (n=304) CHF + anaemia* + CKD** (n=373) CHF + CKD** alone (n=583) CHF alone (n=1393) 14% 11.5% 22% 52.5% Multivariable analysis of data from the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) Program – 2,653 patients with NYHA class II–IV

12 Prevalence of CRAS may be Greater than Current Estimates …about half the patients admitted to hospital with a primary diagnosis of CHF…have anaemia…and the great majority will also have CKI (chronic kidney insufficiency) 1 Silverberg et al. noted the majority of CKI patients with anaemia also had CHF 2 1. Silverberg DS et al. Semin Nephrol 2006;26:296; 2. Silverberg D et al. Nephrol Dial Transplant 2003;18(suppl 8):viii7–viii12

13 Prevalence Data for CRAS are Limited Very few studies have specifically assessed the prevalence of CRAS within the CKD and CHF populations Exclusion criteria for clinical trials often remove patients with CRAS and so a true prevalence of the disorder is unknown


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