Transcript Slide 1

Anaemia management
in people with chronic
kidney disease
September, 2006
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
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
how we define anaemia
a state in which the quality and/or
quantity of circulating red blood cells is
below normal
haemoglobin cut offs in general
population
defining anaemia in people living at sea level
Age or gender group
Haemoglobin below
(g/dl)
Children
6 months to 5 years
11.0
5 to 11 years
11.5
12 to 14 years
12.0
Non-pregnant females
> 15 years
12.0
Males > 15 years
13.0
adverse effects of anaemia
reduced oxygen utilisation
increased cardiac output and left ventricular
hypertrophy
reduced cognition, concentration and libido
reduced immune responsiveness
stages of CKD
Stage
eGFR
(ml/min/1.73m2)
Description
1
> 90
Normal or increased eGFR, with
other evidence of kidney damage
2
60–89
Slight decrease in eGFR, with other
evidence of kidney damage
3
30–59
Moderate decrease in eGFR, with or
without other evidence of kidney
damage
4
15–29
Severe decrease in eGFR, with or
without other evidence of kidney
damage
5
< 15
Established renal failure
how prevalent is anaemia of CKD?
NHANES III data
eGFR
(ml/min/1.73m2
Median Hb in
men (g/dl)
Median Hb in
women (g/dl)
Prevalence
of anaemia
60
14.9
13.5
1%
30
13.8
12.2
9%
15
12.0
10.3
33%
renal anaemia
damaged kidney
impaired production of erythropoietin
reduced number of red blood cells
anaemia
other causes of anaemia in CKD
chronic blood loss
iron deficiency
vitamin B12 or folate deficiency
hypothyroidism
chronic infection or inflammation
hyperparathyroidism
aluminium toxicity
malignancy
haemolysis
bone marrow infiltration
pure red cell aplasia
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
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
diagnosis of anaemia of CKD in
adults
Treat and repeat
Hb
eGFR < 60ml/min/1.73m2
AND Hb ≤ 11 g/dl
Yes
No
Non renal and
haematinic
deficiency excluded?
No
Consider
other causes
Yes
No
See sections
1.2 & 1.3
See initial
management
algorithm
Patient on
haemodialysis?
Yes
initial management algorithm
Yes
No
Ferritin < 500 µg/l?
Ferritin < 200 µg/l?
TSAT < 20% Or
%HRC > 6%
No
Yes
No
Yes – functional
iron deficiency
Assess Hb
Hb > 9 g/dl
Hb < 9 g/dl
ESA
(s.c.or i.v.)
and iron
Hb < 11 g/dl
i.v. iron
Assess Hb
at 6 weeks
Hb > 11 g/dl
ESA
(s.c.or i.v.)
If Hb increase < 1g/dl
after 4 weeks, increase
ESA using dose
schedule
Continue
monitoring Hb
and iron status
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
Hb maintenance algorithm
(assumes ESA therapy and maintenance i.v. iron)
Measure Hb
Hb < 11 g/dl
If Hb is
persistently low
see poor
response
algorithm
↑ ESA dose/
frequency as
per schedule
unless Hb
rising by
1/g/dl/month.
Check Hb
as per
Schedule.
Hb 11–12 g/dl
No change
unless Hb
rising by
1g/dl/month
in which case
consider
ESA dose
adjustment
Hb 12–15 g/dl
Hb > 15 g/dl
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.
Ferritin < 200 µg/l?
monitor treatment
iron status:
haemoglobin:
• not earlier than
1 week after i.v. iron
• induction phase of ESAs
every 2–4 weeks
• routinely at intervals
of between 4 weeks
and 3 months
• maintenance phase of
ESAs every 1–3 months
• more actively after ESA
dose adjustment
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
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
implementation – some
overarching principles
consider having a ‘designated’ contact person(s) who can assume
responsibility for a patient’s 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
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
access tools online
costing tools
• costing report
• costing template
audit criteria
implementation advice
available from: www.nice.org.uk/CG039
access the guideline online
quick reference guide – a summary
www.nice.org.uk/CG039quickrefguide
NICE guideline – all of the recommendations
www.nice.org.uk/CG039niceguideline
full guideline – all of the evidence and rationale
www.nice.org.uk/CG039fullguideline
information for the public – a plain English version
www.nice.org.uk/CG039publicinfo