approach to anemia in chronic kidney disease

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. ‫جيت‬ ‫انا‬
‫وحشتوني‬

3. Protocol of work
By
El-Sahel
Nephrology Department
Teaching staff

4.  1. This patient has anemia due to CKD
 􀀀 Yes
 􀀀 No
 2- Investigate to know which type of anemia
 Hemolytic, aplastic, hemorrhagic, deficiency
 3. HB goal: male 12 g/dl , female 11g/dl
 4. Monitor with monthly labs: CBC
 5. Monitor quarterly: iron, TIBC, transferring saturation
(iron/TIBC), ferritin (See below for iron management)
 6. Before changing dose, consider factors that may temporarily
change Hgb (infection, transfusion, hospitalization, missed
doses, acute blood loss, fluid balance ie dehydration vs. volume
overload); if unclear consult your specialist.
 .IF its iron deficiency anemia workup will done:

5. First of all
proper adequate dialysis
assed by KT/V>1.3

6. Type of iron diff TSAT Ferritin
Absolute <20% <100 ug/ml
Functional <50 Disproportional
>500 ug/ml
maitenance 20-50% 200-500
ug/ml
overload >50% >500 ug/ml

7. absolute iron diff,
Check Ferritin , Tsat,,
WBCs and examine the
patient, HCV+ve pt
will take half dose, or
double duration
TSAT <20 ,
Ferritin>500 mg/dl
Functional Iron
DIff
Iron overload
Hold Iron give Epo
high dose, repeat iron
profile after a month
Give IV iron 100 mg or
lower every 2w or 3w
according to HB , repeat
inves after 3 mon
Iv iron every week
then give Epo after
repleating stores at
least after a month,
high Epo dose and
repeat ininves after
3m
maintenance
dose 100 every 2-
3w according to
HB
Lowest epo
dose
Maintenace
Epo dose
Exclude
infection,
and acute
inflam by
clinically,
WBCs ESR,
CRP

8. HB is higher in HCV +ve pt
so they will need lower Iron dose AND Epo
In HCV +ve pt:
No IV Iron in
Decompensated liver cirrhosis
Acute vial hepatitis
High PCR level
And
Decrease dose of iron needed if liver not cirrhotic
Try to avoid iron if liver is cirrhotic
Contraindicated if decompensated liver cirrhosis

9.  Epoetin dose changes should be made monthly (when
necessary), unless otherwise ordered
 Starting dose indivialization:if HB between 9-10g/dl or give
Epo <9g/dl
 Epotein Beta: 50-150 unit/kg per week
 Darbopoetin alfa (Aranesp)
 Starting dose 0.45mcg/kg/w
 Maintenance dose 0.75mcg/kg/2w
 􀀀 20 mcg sc __________week
 􀀀 30 mcg sc __________week
 􀀀 40 mcg sc __________week
 􀀀 80 mcg sc __________week
 10. Erythropoietin will be titrated to maintain Hgb in target range.
 Evaluate CBC and BP after 4 weeks
 No change in Hgb􀀀 Increase current dose by 1 step (~ 25%)
 Hgb increase ≤ 1 g/dL 􀀀 Cont current dose
 Hgb increase > 1 g/dL (rapid rise) 􀀀 Decrease current dose by 1 step (~ 25%)
 BP Check: increase > 10 mm Hg (systolic or dialstolic) OR SBP >180, DBP >100, notify
consultant

10.  Cont every 4 weeks evaluation with adjustments as above until Hgb rise ≤ 1
g/dL/month and Hgb is within target range; then cont every 4 weeks
evaluation with adjustments as needed to maintain HB in target range. If:
 Hgb ≤9, notify ur specialist
 Hgb ≥9 and < 11, increase current dose by 1 step (~ 25%)
 Hgb 11-12.5, maintain therapy
 Hgb ≥12.5 and ≤13, decrease dose by 1 step (~ 25%) or even hold
 Hgb >13, notify consultant. Hold Epo;
 If. Patients administering epo analog at home, should report blood pressures
Hold Erythropoietin if:
 Hgb >13
 BP>190/110 (notify M.D.)
 Adverse drug reaction Other_________
See chart for stepwise Erythropoietin dose adjustments/conversions between
Epotein (Procrit) and Darbopoetin (Aranesp)

12. .
Red Cell Transfusion to Treat Anaemia in CKD
1-In Acute lose or in chronic anemia in symptomatic pt
2- ESA therapy is ineffective be sure of diagnosis (e.g.
haemoglobinopathies, bone marrow failure, ESA
resistance)
3-The risks of iron or ESA therapy may outweigh its
benefits (e.g.decompensated liver cirrhosis , previous
or current malignancy, previous stroke)
Avoid blood transfusion pt preparing for
transplantation

14. ‫كده‬ ‫كفاية‬
‫عمتو‬ ‫سيبولي‬
‫بقى‬
‫شوبين‬ ‫ورانا‬

15. Thank you