anaemia in ckd ppt

1. Anaemia in CKD
Presented by
Dr.Chinmoy Saha
M.D Resident (Cardiology)

2. Contents
• Anaemia
• CKD
• Causes of anaemia in CKD
• Use of iron to treat anemia in CKD
• Use of ESAs to treat anemia in CKD
• Red cell transfusion to treat anemia in CKD

3. Anaemia
• Anaemia refers to a state in which the level of
haemoglobin in the blood is below the
reference range appropriate for age and sex.

4. Diagnosis of anemia
• In Adults and children >15 years with CKD
Hb% < 13 gm/dl in male
Hb% < 12 gm/ dl in female
• In Children
Age Hb %
.5-5 yr < 11.0 gm/dl
5-12 yr < 11.5 gm/dl
12-15 yr < 12.0gm/dl

5. Investigation
• Complete blood count (CBC) with PBF
• Differential and platelet count
• Absolute reticulocyte count
• Serum ferritin level
• Serum transferrin saturation (TSAT)
• Serum vitamin B12 and folate levels

6. Prevalance of anemia in CKD

7. Monitor of Hb
 For CKD patients without anemia, measure Hb
concentration when clinically indicated and
• at least annually in patients with CKD 3
• at least twice per year in patients with CKD 4–5ND
• at least every 3 months in patients with CKD 5HD and
CKD 5PD
 For CKD patients with anemia not being treated with
an ESA, measure Hb concentration when clinically
indicated and
• at least every 3 months in patients with CKD 3–5ND
and CKD 5PD
• at least monthly in patients with CKD 5HD

8. CKD
• CKD is defined as abnormalities of kidney
structure or function, present for >3 months,
with implications for health

9. Stages of CKD

10. Erythropoiesis

11. Causes of anaemia in CKD

12. Iron Therapy for anaemia in CKD
• Targets:
 Ferritin > 200 microgram/L (heamodialysis)
>100 microgram/L (nonheamodialysis)
 TSAT
>20%
 % HRBC < 6%
 Reticulocyte Hb content >29 pg/cell

13. Recommendation
• For adult CKD patients with anemia not on
iron or ESA therapy a trial of IV iron (or in CKD
ND patients alternatively a 1–3 month trial of
oral iron therapy) if
an increase in Hb concentration without
starting ESA treatment is desired and
TSAT is less equal 30% and ferritin is less
equal 500 ng/ml

14. • For adult CKD patients on ESA therapy who
are not receiving iron supplementations a trial
of IV iron (or in CKD ND patients alternatively
a 1–3 month trial of oral iron therapy) if :
• an increase in Hb concentration or a decrease
in ESA dose is desired and
• TSAT is less equal 30% and ferritin is less
equal 500 ng/ml

15. Monitor
• Evaluate iron status (TSAT and ferritin) at least
every 3 months during ESA therapy,
including the decision to start or
continue iron therapy.
• Test iron status (TSAT and ferritin) more
frequently when
initiating or increasing ESA dose,
when blood loss,
monitoring response after of IV iron,
where iron stores become depleted.

16. Preparation
• Preparation
Oral iron therapy
IV iron therapy
• Adverse Reactions
Anaphylaxis
Hypotension
Nausea,vomiting,pruritus,dizziness

17. EPO
• EPO is a 165 amino acid secreted glycoprotein
that is required for erythrocyte maturation
• It is produced by peritubular interstitial
fibroblast
• If GFR is normal,EPO level is inversely
propotional to Hb.

18. EAS

19. Types
ESA Half Life Initial dosing
Epoetin 4-8 hr 80-120 u/kg in 3
divided dose
Epoetin 4-12 hr 80-120 u/kg in 3
divided dose
Darbepoetin 21-25hr .45microgram/kg
weekly
Methoxy Polyethylene
glycol
130 hr .6microgram/kg
fortnightly,then
monthly

20. ESA therapy
• Address all correctable causes of anemia
(including iron deficiency and inflammatory
states) prior to initiation of ESA therapy.
• The objectives of initial EAS therapy is a rate
to increase Hb 1-2 g/dl per month.

21. Frequency of monitoring
During the initiation phase of ESA therapy,
• measure Hb concentration at least monthly
• For CKD ND patients, during the maintenance
phase of ESA therapy measure Hb concentration
at least every 3 months. (Not Graded)
• For CKD 5D patients, during the maintenance
phase of ESA therapy measure Hb concentration
at least monthly. (Not Graded)

22. KDIGO Recommendation
• For adult CKD ND patients with Hb concentration >10.0
g/dl ESA therapy not to be initiated.
• For adult CKD ND patients with Hb concentration <10.0 g/dl
to initiate ESA therapy based on
• the rate of fall of Hb concentration,
• prior response to iron therapy,
• the risk of needing a transfusion,
• the risks related to ESA therapy and
• the presence of symptoms attributable to anemia.
• For adult CKD 5D patients, ESA therapy is to be used when
the hemoglobin is between 9.0–10.0 g/ dl (90–100 g/l).

23. Red cell transfusion in CKD
Indication of Blood transfusion
• When rapid correction of anemia is required to
stabilize the patient’s condition e.g.,acute
hemorrhage
• When rapid pre-operative Hb correction is required
• When symptoms and signs related to anemia are
present in patients in whom ESA therapy is
ineffective.
• When symptoms and signs related to anemia are
present in patients in whom the risks of ESA therapy
may outweight the benefits

24. Alogorithm

25. THANK YOU