Transcript Slide 1

update of Anemia management in
chronic kidney disease
What is still missing
What makes the standards
• Guidelines
• Own experience
• Economic status
This way
STILL MISSING
Aim of treatment
Iron management
Statistics
Early Transferal
Strategies for treating renal anemia
Hb Sweet
Spot
Hb (g/dl)
Prevention
Higher
target
15
2002
1998
1994
10
Earlier
start
1990
5
Dialysis
Time or GFR
Hb Trade Offs
Death and CV Complications
Hypertension
Faster progression of CKD
Increased Risk of Stroke
Vascular access thrombosis
Low Hb
Tiredness and exhaustion
Poor quality of life
High transfusion rate
Higher rate of death and CV complications
High Hb
March 9, 2007
The Hemoglobin Sweet Spot
Risk
100%
50%
9
11
12
13
Hb
g/dL
March 9, 2007
From monitor
to
Close monitor
Step 1
Insert the
TEST CARD
Step 2
Apply the
SAMPLE
Step 3
Read the
RESULT in 2 min
STILL MISSING
Aim of treatment
Iron management
Statistics
Early Transferal
Erythropoiesis
+
+
Iron
EPO
─
Pro-inflammatory
cytokines
(IL-1, TNFα, IL-6, IFNγ)
Hepcidin
Apoptosis
─
 Fe absorption
 Fe transport
 Fe availability
(EPO-R, Tf, TfR,
Ferriportin, DMT-1)
Why are CKD patients prone to develop iron deficiency
REDUCED INTAKE
INCREASED LOSSES
•
Poor appetite
•
Occult G-I losses
•
Poor G-I absorption
•
Peptic ulceration
•
Concurrent medication –
•
Blood sampling
e.g. omeprazole
•
Dialyser losses
Food interactions
•
Concurrent meds. –
•
e.g. aspirin
•
Heparin on dialysis
Am J Nephrology 2007
Non – haematological benefits of iron
Iron
Physical Performance
Thermoregulation
Cognitive Function
Restless legs
Haemoglobin
Immune function
Clinical issues in iron deficiency in CKD
• Assessing iron status
• Oral versus intravenous medication
• Iron management in CKD
Assessing iron status
• Quantification of iron stores
• Measurement of available iron in blood
• Assessment of iron uptake and utilisation by marrow
Assessing iron status
• Quantification of iron stores
• Serum ferritin, bone marrow stainable iron
• Serum ferritin is acute phase protein
Assessing iron status
• Measurement of available iron in blood
• Transferrin saturation =
100 X serum iron
serum total iron binding capacity
Assessing iron status
• Assessment of iron uptake and utilisation by marrow:
% hypochromic red cells, RBC zinc protophoryin
Recommended Targets for Iron Status in CKD
K-DOQI
European Best
practice
Guidelines
National Institute
for Clinical
Excellence
(NICE)
Serum Ferritin
>100ng/ml (nondialysis).
>200ng/ml
(dialysis)
>100ng/ml (target
200-500ng/ml)
>100ng/ml
target 200-500
ng/ml
ceiling
Not
routinely>500ng/
ml
Transferrin
>20%
Saturation (TSAT)
>20%
>20% unless
ferritin>800ng/ml
% Hypochromic
Red Cells
<10% target
<2.5%
<6% unless
ferritin >800ng/ml
---
CHr – reticulocyte >29pg/cell
haemoglobin
>29pg/cell target
= 35pg/cell
Frequency of iron status tests:
1- Every month during initial ESA treatment
2- At least every 3 months during stable ESA
treatment or in patients with HD-CKD not treated
with an ESA
© 2006 National Kidney Foundation, Inc.
NKF KDOQI GUIDELINES
< 100 ng/ml
100 -174 ng/ml
175 - 225 ng/ml
(200 ng/ml)
226 - 800 ng/ml
(400 ng/ml)
> 800 ng/ml
Ferritin assessment in 10 min
invalid
Vs
Oral Iron
I.V. Iron
Reports/million 100 mg
dose equivalents
FDA reported allergic reactions to IV iron: Jan 1997-Sep 2002
30
all event
all fatal event
20
10
0
dextran
Bailie et al. NDT 2005,20,1443-1449
gluconate
sucrose
Heme – Iron polypeptide
• Derived from bovine haemoglobin
• Oral bioavailabilty 10 times greater than
conventional oral iron
• Reduced GI side effects
Heme – Iron polypeptide
STILL MISSING
Aim of treatment
Iron management
Statistics
Early Transferal
Statistics
Incidence:
Prevalence:
Measure of new patients entering ESRD/Dialysis
Measure of patients undergoing dialysis
Africa:
ME
Incidence ~
Prevalence ~
? P.M.P
? P.M.P
A need for more accurate data in most of the countries
to plan for the future
STILL MISSING
Aim of treatment
Iron management
Statistics
Early Transferal
Transferal & Decision to treat
65% transferred when in need for urgent dialysis ( KSA)
How many patients treated for their anemia in our region?
How many patients reach target Hgb in our region?
Conclusion
More frequent monitor for Hb &iron
limiting ESA when Hb over 12g/dl
Optimum iron therapy lower ESA dose
A need for more accurate data related to Incidence
&Prevalence
Screening program for early transferral is needed
Thank you and any questions ???