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Anaemia management in people with chronic kidney disease September, 2006.

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Presentation on theme: "Anaemia management in people with chronic kidney disease September, 2006."— Presentation transcript:

1 Anaemia management in people with chronic kidney disease September, 2006

2 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

3 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

4 how we define anaemia a state in which the quality and/or quantity of circulating red blood cells is below normal

5 haemoglobin cut offs in general population defining anaemia in people living at sea level Age or gender groupHaemoglobin below (g/dl) Children 6 months to 5 years to 11 years to 14 years12.0 Non-pregnant females > 15 years 12.0 Males > 15 years13.0

6 adverse effects of anaemia reduced oxygen utilisation increased cardiac output and left ventricular hypertrophy reduced cognition, concentration and libido reduced immune responsiveness

7 stages of CKD Stage eGFR (ml/min/1.73m 2 ) Description 1> 90Normal or increased eGFR, with other evidence of kidney damage 260–89Slight decrease in eGFR, with other evidence of kidney damage 330–59Moderate decrease in eGFR, with or without other evidence of kidney damage 415–29Severe decrease in eGFR, with or without other evidence of kidney damage 5< 15Established renal failure

8 how prevalent is anaemia of CKD? NHANES III data eGFR (ml/min/1.73m 2 Median Hb in men (g/dl) Median Hb in women (g/dl) Prevalence of anaemia % % %

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

10 other causes of anaemia in CKD chronic blood loss iron deficiency vitamin B 12 or folate deficiency hypothyroidism chronic infection or inflammation hyperparathyroidism aluminium toxicity malignancy haemolysis bone marrow infiltration pure red cell aplasia

11 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

12 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

13 diagnosis of anaemia of CKD in adults eGFR < 60ml/min/1.73m 2 AND Hb 11 g/dl No Consider other causes Yes Non renal and haematinic deficiency excluded? No Treat and repeat Hb Yes Patient on haemodialysis? No See sections 1.2 & 1.3 Yes See initial management algorithm

14 initial management algorithm Ferritin < 500 µg/l? No Yes Ferritin < 200 µg/l? Yes No TSAT < 20% Or %HRC > 6% No Yes – functional iron deficiency Assess Hb ESA (s.c.or i.v.) Hb > 9 g/dlHb < 9 g/dl i.v. iron ESA (s.c.or i.v.) and iron Assess Hb at 6 weeks Hb < 11 g/dl Hb > 11 g/dl Continue monitoring Hb and iron status If Hb increase < 1g/dl after 4 weeks, increase ESA using dose schedule

15 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

16 Hb maintenance algorithm (assumes ESA therapy and maintenance i.v. iron) Measure Hb Hb < 11 g/dlHb 11–12 g/dlHb 12–15 g/dlHb > 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 < 200 µg/l?

17 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 2–4 weeks maintenance phase of ESAs every 1–3 months more actively after ESA dose adjustment

18 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

19 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

20 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


22 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

23 access tools online costing tools costing report costing template audit criteria implementation advice available from:

24 access the guideline online quick reference guide – a summary NICE guideline – all of the recommendations full guideline – all of the evidence and rationale information for the public – a plain English version

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