Anemia pres 20 feb 2017

1. Anemia in CKD
Hussein Sheashaa, MD, FACP
Professor of Nephrology, Urology and Nephrology Center and Director of
Medical E-Learning Unit, Mansoura University and Executive Director of ESNT-
Virtual Academy: http://lms.mans.edu.eg/esnt/
Mansoura UNC, Feb 20th, 2017

3. 1. Introduction
2. Iron
3. ESA
4. Adjuvants
5. ESA resistance
6. HIF Stabilizers
7. Special Issues
Corners

4. NCGC, AMCKD update, June 2015
Definition of Anemia

5. Impact of Anemia:
2602 Japanese Patients
Clin Exp Nephrol (2016) 20:595–602

6. Quality-of-life Sexual function
Exercise capacity Endocrine function
cardiac output Immune function
Angina Muscle metabolism
LVH Hospitalizations
Bleeding tendency Transfusions
Brain / cognitive function Nutrition
Depression
Sleep patterns
Anemia Control:
Benefits

7. Kidney International Supplements (2012), 299–310
CKD Associated Anemia:
Potential Factors
ESA Deficiency

8. 1. Introduction
2. Iron
3. ESA
4. Adjuvants
5. ESA resistance
6. HIF Stabilizers
7. Special Issues
Corners

9. NCGC, AMCKD update, June 2015
Diagnosis of Anemia:
Iron Status

10. Am J Kidney Dis. 2016 March 2016 ;67(3):367-75.
Iron Therapy:
Evolution
750 mg (IV)

11. NCGC, AMCKD update, June 2015
Oral Iron Preparations:
Iron Contents

12. Parenteral Iron:
Doses

13. Am J Kidney Dis.November 2016;68(5):677-690
Iron Therapy:
IV Versus Oral

14. Nephrol Dial Transplant (November 2016) 31: 1835–1845
IV Iron Therapy:
Effects on Monocytes
Iron sucrose and sodium ferric gluconateFerric carboxymaltose and iron isomaltoside

15. IV Iron Therapy:
Effects on Renal Function
BMC Nephrology (2017) 18:24

16. Phosphorus and Anemia
RCT 411 (FC: Active control), 52 W
Saving 2101 USD/P/Y

17. Nephrol Dial Transplant (December 2015) 30: 2019–2026
CRUISE
Continuous Replacement Using Iron Soluble
Equivalents: Phase 3, RCT, n 599, 48 w

18. 1. Introduction
2. Iron
3. ESA
4. Adjuvants
5. ESA resistance
6. HIF Stabilizers
7. Special Issues
Corners

19. Current ESAs
Am J Nephrol 2017;45:235–247 Published online: February 1, 2017

20. New Strategies:
Stimulate Erythropoiesis
Am J Kidney Dis. 2016 Jan;67(1):133-42.

21. Refrigeration
Room Temperature Shelf Life
0
5
7
31
0 5 10 15 20 25 30 35
Darbepoetin alfa
Epoetin beta
Epoetin alfa
Days
C.E.R.A.

22. ESA Initiation

23. Conversion Among ESA

24. Short Acting ESA Therapy:
Frequency
Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD011690

25. The Cochrane Library 2014, Issue 12
Which ESA Therapy?
56 Studies, 15.596 Patients

26. The Cochrane Library 2014, Issue 12
Which ESA Therapy?

27. KDIGO 2012:
ESA Strategy
VOLUME 2 | ISSUE 4 | AUGUST 2 2012
http://www.kidney-international.org
OFFICIALJOURNALOFTHEINTERNATIONALSOCIETYOFNEPHROLOGY
KDIGOClinicalPracticeGuidelineforAnemiainChronicKidneyDisease

28. Transfusion and Apheresis Science 50 (2014) 16–19
ESA Therapy:
Suggested Contraindications

29.  Worsening of HTN
 Seizure
 Increased blood clotting
 Slight decrease of Kt/ V
 Impaired phosphorus balance
 Hyperkalemia
 Pure Red cell aplasia (PRCA)
Adverse Effects of ESA
Therapy

30. ESA Route:
Outcome

31. 1. Introduction
2. Iron
3. ESA
4. Adjuvants
5. ESA resistance
6. HIF Stabilizers
7. Special Issues
Corners

32. Kidney International Supplements (2012), 299–310VOLUME 2 | ISSUE 4 | AUGUST 2 2012
http://www.kidney-international.org
OFFICIALJOURNALOFTHEINTERNATIONALSOCIETYOFNEPHROLOGY
KDIGOClinicalPracticeGuidelineforAnemiainChronicKidneyDisease
KDIGO 2012:
Adjuvant Therapy

33. 1. Introduction
2. Iron
3. ESA
4. Adjuvants
5. ESA resistance
6. HIF Stabilizers
7. Special Issues
Corners

34. Am J Kidney Dis. November 2016;68(5):763-771
ESA
Hyporesponsiveness

35. ESA Hypo-responsiveness:
Effect of Hepcidin
Am J Nephrol 2017;45:187–199

36. Nephrol Dial Transplant (2015) 30: 682–689
ESA Hypo-responsiveness:
Effect of Dialyzer Type

37. Seminars in Dialysis—Vol 28, No 5 (September–October) 2015 pp. 530–532
ESA Hypo-responsiveness:
Effect of Graft Failure

38. 1. Introduction
2. Iron
3. ESA
4. Adjuvants
5. ESA resistance
6. HIF Stabilizers
7. Special Issues
Corners

39. Nat. Rev. Nephrol. 11, 394–410 (2015); published online 9 June 2015
Anemia Control:
Effect of Hypoxia

40. Am J Nephrol 2017;45:187–199
HIF Stabilizers

41. HIF Stabilizers

42. Clin J Am Soc Nephrol 11: 982–991, 2016
HIF Stabilizers:
Roxadustat (Phase 2b)

43. J Am Soc Nephrol 27: 1225–1233, 2016
HIF Stabilizers:
Roxadustat

44. 1. Introduction
2. Iron
3. ESA
4. Adjuvants
5. ESA resistance
6. HIF Stabilizers
7. Special Issues
Corners

45. Nephrol Dial Transplant (Feb 2017) 32: 279–287
ESA Therapy:
Reno-protection

46. Kidney International Supplements (2012), 299–310
Pure Red Cell Aplasia:
2012 KDIGO Guidelines
VOLUME 2 | ISSUE 4 | AUGUST 2 2012
http://www.kidney-international.org
OFFICIALJOURNALOFTHEINTERNATIONALSOCIETYOFNEPHROLOGY
KDIGOClinicalPracticeGuidelineforAnemiainChronicKidneyDisease
X

47. Critical Reviews in Oncology/Hematology 87 (2013) 132–139
ESA Therapy and Cancer
Associated Anemia

48. ESA Therapy and Chemotherapy
Induced Anemia
Onco Targets Ther. 2016 Oct 28;9:6689-6693

49. Nephrol Dial Transplant 2016, in press
ESA Therapy and Cancer

50. (n 4,983)
Br J Clin Pharmacol. 2012 Jul 16.
Hemoglobin Variability:
Effect of Different ESA

51. Kidney International (2016) 90, 422–429
Anemia Control Model:
ACM

52. J Am Soc Nephrol 27: 3129–3138, October 2016
Current Trends

53. 15
14
10
11
12
13
9
Hb(g/dl)
2017 Target
Anemia Management:
Hemoglobin Target