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Anemia in chronic kidney disease

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Presentation on theme: "Anemia in chronic kidney disease"— Presentation transcript:

1 Anemia in chronic kidney disease
Iron metabolism And Anemia in chronic kidney disease Chittima Sirijerachai

2 Iron distribution Intracellular iron Extracellular iron
Intracellular ferrous iron Heme iron compound : Hb, myoglobin Iron containing enzyme Intracellular ferric iron RE cell, heart, epithelial cell of small intestine Extracellular iron - Ferric-transferrin

3 utilization utilization Myoglobin 300 mg Bone marrow 300 mg
Erythrocyte 1800 mg utilization Dietary iron 1-2 mg/day Plasma transferrin 3 mg Liver 1000 mg Spleen 600 mg Slough mucosal cell 1-2 mg/day

4 Iron absorption Fe+++ Fe++ Fe++ Fe+++ - transferrin Promote absorption
Fructose Vitamin C Heme iron Amino acid Fe+++ HCl Fe++ Inhibit absorption Phosphate Phytate Tannin Soil clay Fe++ Fe++ ferritin Fe+++ - transferrin

5 Iron absorption

6 Regulation of iron absorption
Dietary iron – mucosal block Iron stores – store regulator Erythropoitic regulator

7 Iron utilization Heme

8 Iron deficiency anemia
Myoglobin 300 mg utilization Bone marrow 300 mg Erythrocyte 1800 mg utilization Dietary iron 1-2 mg/day Plasma transferrin 3 mg Liver 1000 mg Spleen 600 mg Slough mucosal cell 1-2 mg/day

9 Anemia of chronic disease
inflammation Anemia of chronic disease Liver spleen hepcidin hepcidin Plasma Fe-Tf rbc Bone marrow

10 Iron study Serum iron Total iron binding capacity (TIBC)
Transferrin saturation (Tf sat) Ferritin

11 Serum ferritin (ng/ml)
Iron depletion normal functional absolute erythrocyte Iron stores Serum ferritin (ng/ml) > 100 < 100 Tf sat % > 20 < 20

12 - iron - protein - etc Decreased production Increased destruction
erythropoietin Blood loss Increased destruction

13 Causes of anemia in ESRD
Decrease erythropoietin Iron deficiency Nutritional deficiency Decrease red cell survival Bone marrow suppression by uremia Osteitis fibrosa cystica Inflammation Aluminum toxicity

14 Work-up for a diagnosis of
anemia in CKD Hb Adult male < 13.5 g/dl Adult female <12.5 g/dl

15 Diagnosis of renal anemia
Significant impairment of renal function GFR < 30 cc/min, Cr > 2 mg/dl No other causes of anemia Iron deficiency anemia Nutritional deficiency anemia

16 Diagnosis of renal anemia
History taking - Dietary intake - Chronic blood loss Physical examination


18 Investigation CBC Red cell indices Iron study, ferritin

19 CBC and RBC indices 80-96 fl. 27-33 pg. 33-36 g/dl %


21 Iron study, ferritin TSAT < 20 % Ferritin < 100 ng/ml
Iron deficiency anemia

22 Treatment of renal anemia

23 Benefit of anemia control in ESRD
Increased survival Decreased cardiac complication Improved quality of life Increased exercise capacity Decreased hospitalization

24 Target for anemia treatment
Hb > 11 g/dl Hct > 33 % Within 4 months Ferritin ng/ml TSAT %

25 Treatment of renal anemia
Iron therapy Eryhtropoietin Adequate dialysis Nutritional support


27 Iron therapy Improved response to EPO Reduced dose of EPO

28 Iron therapy IV iron Iron sucrose (venofer) Oral iron VS

29 Iron therapy - Ferrous sulfate 1 x 3 - Iron sucrose 25-150 mg/wk
Monitor:- serum ferritin, TSAT q 1-3 months

30 Iron therapy in CKD Serum ferritin Transferrin saturation
< 100 ng/ml - iron deficiency > 800 ng/ml - stop iron Rx Transferrin saturation < 20 % - iron deficiency > 50 % - stop iron Rx

31 Side effects of iron therapy
GI irritation Diarrhea Constipation Oral iron anaphylactoid hypotension muscle cramp IV iron

32 Erythropoietin Erythropoietin a Erythropoietin b Eprex Eporon Epokrine

33 Erythropoietin U/kg/wk SC U/kg/wk IV Hb 1-2 g/dl/month

34 Erythropoietin Side effects - hypertension - headache - PRCA
- Thrombosis

35 Inadequate erythropoietin response
Patient fail to attain the target Hb while receiving:- EPO 300 U/kg/wk SC EPO 450 U/kg/wk IV 4-6 months

36 Inadequate erythropoietin response
Iron deficiency anemia Chronic blood loss Chronic inflammation Inadequate dialysis hyperparathyroidism


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