1. Clinical management of anaemia in a patient with chronic kidney disease not-on-dialysis
Jolanta Malyszko, MD
Department of Nephrology and Transplantology
Medical University of Bialystok, Poland
© Springer Healthcare, a part of Springer Science+Business Media; 2010.

2. Objectives
Focus on anaemia in CKD and DM, including prevalence and outcome
Case report: Diagnosis of anaemia
Treatment: Iron supplementation and ESA therapy
Hb variability: Practical considerations
Safety issues with ESA therapy
CKD: chronic kidney disease; DM: diabetes mellitus; Hb: haemoglobin; ESA: erythropoiesis-stimulating agent
© Springer Healthcare, a part of Springer Science+Business Media; 2010.

3. CKD anaemia: A common complication
Anaemia associated with CKD is a major complication even in early stages
Hb decreases progressively with the degree of renal impairment1
CKD anaemia occurs earlier in patients with type 2 diabetes2
CKD: chronic kidney disease; Hb: haemoglobin
1. Jungers. Nephrol Dial Transplant 2002; 17: , 2. Joss, et al. QJM 2007;100:641-47
© Springer Healthcare, a part of Springer Science+Business Media; 2010.

4. Multiple choice question 1
Which of the following statements are true?
Anaemia associated with CKD is a major complication even in its early stages.
Haemoglobin remains stable despite the degree of renal impairment.
Among patients with diabetes, CKD anaemia occurs earlier than among non-diabetics.
A: 1
B: 1 & 3
C: All of the above
D: None of the above
CKD: chronic kidney disease
© Springer Healthcare, a part of Springer Science+Business Media; 2010.

5. CKD anaemia with diabetes
Correlates with eGFR
Stage 4+ 60
Stage 3
macroalbuminuria 45
Stage 2
Prevalence anaemia (%) 30
Stage 1
microalbuminuria 15
normoalbuminuria
>90
60-90
30-60
<30
eGFR (mL/min/1.73m2)
eGFR: estimated glomerular filteration rate
Adapted from Thomas, et al. Nephrol Dial Transplant 2004; 19:
© Springer Healthcare, a part of Springer Science+Business Media; 2010.

6. DM: diabetes mellitus; tid: 3 times a day; qd: once a day
Case report
Caucasian female born in 1956, high-school teacher
Type 2 DM diagnosed at 33 years of age, treated with metformin (850 mg tid) and glimepiryde (3 mg qd)
Surgery for ovarian abscess at 44 years of age
Problems with blood pressure control at 45 years of age
Under diabetologist care
DM: diabetes mellitus; tid: 3 times a day; qd: once a day
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7. Nephrology findings
1st nephrology consultation at 50 years of age (Oct 2006) owing to poor blood pressure control
Creatinine: 1.07 mg/dL; Hb: 12.6 g/dL, Hct: 38%; total cholesterol: 233 mg/dL
Other medications: Indapamide SR; simvastatin 20 mg bedtime; quinalapril 5 mg
ABPM: Mean SBP 162 mgHg; mean DBP 91 mmHg; non dipper
Urinary protein excretion: 3.4 g/d
ABPM: ambulatory blood-pressure monitoring; SBP: systolic blood pressure; DBP: diastolic blood pressure
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8. Additional findings and recommendations
Leg oedema
Urinary glucose: 0.26g/L
Potassium: 5.46 mmol/L; sodium: 141 mmol/L
TSH: mIU/L
Quinapril: ↑10 mg qd
Add telmisartan: 80 mg qd
Furosemide: 40 mg qd
Refused insulin therapy
TSH: thyroid-stimulating hormone; qd: once a day
© Springer Healthcare, a part of Springer Science+Business Media; 2010.

9. 1st nephrology hospitalisation
51 years of age (Dec 2007), owing to nephrotic syndrome, UAE- 8 g/d; albumin: 2.6 g/dL; protein: 5.5 g/dL
Fasting glucose: 255 mg/dL; 2h post-meal: 280 mg/dL; urinary glucose: mg/dL; creatinine: 1.26 mg/dL; eGFR (MDRD): 48 mL/min
Hb: 10.5 g/dL; Hct: 30.7%; MCV: 84.8 fl
CRP: 1.3 mg/L
Chol: 200 mg/dL; TG: 177 mg/dL
Simple diabetic retinopathy
Antihypertensives continued, insulin therapy refused
Oral iron started
UAE: urinary albumin excretion; eGFR: estimated glomerular filtration rate; MDRD: modification of diet in renal disease;
Hb: haemoglobin; MCV: mean corpuscle volume; CRP: c-reactive protein; TG: triglyceride
© Springer Healthcare, a part of Springer Science+Business Media; 2010.

10. Outpatient unit March 2008: Hb 10.8 g/dL; oral iron June 2008:
Iron: 56 μg/mL; TIBC: 263 μg/mL; TSAT: 21%;
Ferritin: ng/mL; Hb: 9.0 g/dL; Hct: 26.4%; plt: 464 x 103/mL; WBC: 11.26x106/mL; CRP: 0.2 mg/L; creatinine: 1.88 mg/dL; eGFR: 34 mL/min
Darbepoetin (20 μg) Q2W then 40 μg QM
Hb rose to 9.8 g/dL then 10.5 g/dL after 4 months
Hb: haemoglobin; TIBC: total iron binding capacity; TSAT: transferrin saturation; Hct: haematocrit; eGFR: estimated glomerular filteration rate; Q2W: once every 2 weeks; QM: once a month; CRP: C-reactive protein; WBC: white blood cells; Hct: haematocrit
© Springer Healthcare, a part of Springer Science+Business Media; 2010.

11. 2nd nephrology hospitalisation
Dec 2008: fall in Hb despite ESA therapy
Hb: 8.5 g/dL; Hct: 25.6 %
Ferritin: 104 ng/mL; TSAT: 21%; CRP: 2.2 mg/L; creatinine: mg/L; eGFR (MDRD): mL/min; urinalysis protein: 100 mg/dL; glucose: 363 mg/dL; albumin: 3.4 g/dL; tprotein: 6.7 g/dL
IV iron and ESA continued
ESA: erythropoiesis-stimulating agent, eGFR: estimated glomerular filteration rate, MDRD: modification of
diet in renal disease; tprotein: total protein; CRP: C-reactive protein; Hct: haematocrit; Hb: haemoglobin; TSAT: transferrin saturation
© Springer Healthcare, a part of Springer Science+Business Media; 2010.

12. 3rd nephrology hospitalisation
Feb 2009: Hb 10.2 g/dL; April Hb: 11.5 g/dL; darbepoetin alfa: 40 μg/month
May 2009: 3rd nephrology hospitalisation
Hb: 9.2 g/dL; CRP: 0.4 mg/dL; Fe: 35 μg/dL; TSAT: 14%; ferritin: 131 ng/mL; CEA: 2.5 ng/mL (N: 0-3 ng/mL); Ca-125: 237 mIU/mL; (N: 0-35 mIU/mL), tprotein: 7.1 g/dL; creatinine: 4.21 mg/dL
Insulin therapy introduced
Ascites, ovarian tumour: surgery
Ovariectomy and hysterectomy: ovarian cystadenoma
Hb: haemoglobin, CRP: C-reactive protein, Fe: iron, TSAT: transferrin saturation, CEA: carcinoembryonic antigen,
Ca: calcium
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13. Post-surgical course IV iron supplementation
Creatinine: mg/dL; eGFR: mL/min
Hb: 9.8 g/dL; after 1 g of IV iron ESA reintroduced in June 2009
Creatinine stable mg/dL
Hb rose to 11.5 /dL (August 2009), then 12.2 g/dL; darbepoietin alfa dose 20 μg/month, then Hb 11.7 g/dL (Oct 2009), continue ESA 20 μg/month
Hb stable: g/dL
Hb: haemoglobin; ESA: erythropoiesis-stimulating agent; eGFR: estimated glomerular filteration rate
© Springer Healthcare, a part of Springer Science+Business Media; 2010.

14. Multiple choice question 2
The patient’s haemoglobin has reached 13.2 g/dL; she asks her physician whether her ESA therapy should be continued. Your possible answer is:
A: As her quality of life has improved, I would continue ESA therapy
B: I would lower the dose of ESA by 25%
C: I would discontinue ESA therapy
D: None of the above
© Springer Healthcare, a part of Springer Science+Business Media; 2010.

15. Safety considerations
Cystadenoma: Continue with ESA?
IV iron without an ESA results in a fall in Hb
Continue with careful gynaecological monitoring
ESA: erythropoiesis-stimulating agent
© Springer Healthcare, a part of Springer Science+Business Media; 2010.

16. Conclusions ESA therapy is effective in the clinical management of CKD
Darbepoetin alfa administered monthly was effective and Hb levels were stable
In patients with a history of malignancy, periodic monitoring is warranted
ESA: erythropoiesis-stimulating agent; CKD: chronic kidney disease; Hb: haemoglobin
© Springer Healthcare, a part of Springer Science+Business Media; 2010.