Evaluation and management of Anemia in CKD

1. Presentation by :
Dr Binay Kumar
Senior Resident
DepT of Medicine
BMIMS PAWAPURI
Evaluation and Management of Anemia in CKD

2. Causes of Anemia in CKD
1. Relative erythropoietin deficiency(most important)
2. Diminished red blood cells survival
3. Bleeding diathesis
4. Iron deficiency
5. Hyperparathyroidism/bone marrow fibrosis
6. Chronic inflammation
7. Vitamin B12 or Folate deficiency
8. Blood loss during dialysis
9. Comorbid conditions-Hypo/hyperthyroidism,
pregnancy,HIV, Autoimmune disease,
immunosuppressive drugs

3. Evaluation of Anemia in CKD
A.Screening for anemia
Annually in CKD G 1-3
6 monthly in CKD G 4
3 monthly in CKD G 5 on HD
B.Hb level
CKD with Hb <11gm/dl
With symptoms attributable to Anemia

4. C.Renal function
CKD should be considered as a possible cause of
anaemia when the glomerular filtration rate (GFR)
is <60 ml/min/1.73m2
D.Serum Erythropoietin
should not routinely be considered for the
diagnosis or management of anaemia in CKD.

5. E. Baseline investigations
CBC with Red cell indices
PBS
Absolute reticulocyte count
Iron profile (%Transferrin saturation, Serum
ferritin,TIBC)
Stool guaiac test
Serum Folate,Vit B12
Bone marrow aspiration/biopsy

6. Iron status
Presence or absence of storage iron -Serum
ferritin
Availability of Iron to support ongoing
erythropoiesis-TSAT(Serum iron ×100/TIBC)

7. Treatment Options
Iron(intravenous/oral)
Erythropoiesis stimulating agents (ESA)
Blood transfusion
Folic acid and Vit B12

8. When to start iron therapy?
For adult CKD patients with anemia not on iron or ESA
therapy,a trial of iv iron (or in CKD ND patients
alternatively a trial of 1-3 months of oral iron
therapy)if:
1. An increase in Hb concentration without ESA
treatment is desired
2. TSAT is <30% and ferritin is <100mcg/L

9. For adult CKD patients with anemia on ESA
therapy,who are not receiving iron supplements ,a
trial of iv iron (or in CKD ND patients alternatively a
trial of 1-3 months of oral iron therapy)if:
1. An increase in Hb concentration or a decrease in
ESA dosing is desired
2. TSAT is <30% and ferritin is <100mcg/L

10. When should not to give iron?
Routine use of iron supplementation in patients
with TSAT >30% or serum ferritin>500mcg/L is not
rrecommended

11. When to suspect iron overload?
If serum ferritin level in patients on iron
therapy > 800mcg/L,in absence of any
inflammation (serum CRP- normal)

12. IV or Oral
Iron
• Parenteral therapy is the recommended route for all CKD
patients, because of poor oral absorption in this state.
• Most CKD patients receiving ESA treatment require
parenteral iron therapy to meet increased requirements.
• Oral therapy is limited by poor absorption and non
adherence with therapy due to adverse effects.
• Consider oral iron supplements in ND or PD patients
without iv access or maintenance therapy in ND or PD
patients.

13. Oral iron is typically prescribed to provide
approximately 200mg of elemental iron daily
(for instance ferrous fumarate 300 mg twice daily
,each pill provide 98.6 mg elemental iron)
Liposomal iron and citrate forms are newer
formulations having better git absorption and
tolerance.

14. Iron Formulations
Oral formulations- sulphate, ascorbate, fumarate,
polysaccharide complex,liposomal iron,citrate
(newer)
Parenteral(IV) formulations- dextran, gluconate,
sucrose
Newer- ferric carboxymaltose, ferumoxytol, and
iron
isomaltoside
Newer formulations are associated with significantly
fewer side effects.

15. Monitoring Therapy
Tests Recommended range
Serum ferritin 100-500 mcg/L
Transferrin saturation 20-40%
Hypochromic red cells <10%
Reticulocyte Hb content >29pg/cell
Markers of Iron status in CKD Patients

16. ESA THERAPY

17. Types of erythropoiesis stimulating
agents [ESA]
First generation ESA
Erythropoietin alpha(T1/2- 21 hours after sc)
Erythropoietin beta(T1/2- 21 hours)
Second generation ESA
Darbepoietin(T1/2- 25 hours)
Third generation ESA
CERA(continuous erythropoietin receptors activator)
(T1/2-7 days)

18. ESA THERAPY
A.When to start ESA therapy
1.Serum ferritin level>100mcg/L
2.Failure of iron therapy
3.Transplant candidate requiring blood
transfusion.
Exclude all correctable causes before starting
ESA therapy
Should not be started in absolute iron
deficiency (ferritin<100mcg/L)

19. B. ESA dosing

20. C. Target Hb level
Objective of initial ESA therapy is to increase Hb
level of 1.0-2.0 gm/dl(10-20gm/L) per month
Rise of Hb level >2 gm/dl (20gm/dl) over a 4-weeks
period should be avoided
Target Hb – not to exceed >11.5 gm/dl
Hb monitored and dose adjustment made every 4
weekly
Once stable Hb level achieved, monitor 3 monthly
Or in between any incurrent illness.

21. D. Dose modifications
If Hb level increases by >2gm%/month , decrease
the dose of ESA by 25%
If Hb level not increases by >1gm%/month, increase
the dose of ESA by 25%

22. E. Poor response to ESA therapy

23. F. ESA resistance
Resistance to ESA therapy is defined as failure to
reach the target Hb level despite SC epoetin dose
>300 IU/kg/week (450 IU/kg/week IV epoetin) or
darbepoetin dose >1.5 microgram/kg/week.

24. G. Adverse events of rHuEPO
Hypertension-30%
Hypertensive encephalopathy
Increased risk of thromboembolic phenomena, like
stroke, MI, venous thrombosis.
Seizure
Potential risk of cancer progression
Pure red cell aplasia (PRCA)
Minor like infection,rashes, itching, headache

25. Take Home Messages ✉️✉️✉️…
Anemia is significant contributor to morbidity and
mortality in CKD, don’t focus on Hemodialysis always.
Don’t go fast , over correction of anemia in this condition
is always associated with poor outcomes [target Hb rise 1-
2g/dl/month]
First replete iron storage then start ESA therapy.
It is better to avoid blood transfusion, but there are some
situations where it may be mandatory. RISK vs BENIFIT

26. You care for your
kidneys
Kidneys care for
you

27. Thank You