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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 ???