Anaemia management in people with chronic kidney disease

1. Anaemia management in people with chronic kidney disease September, 2006

2. changing clinical practice • NICE guidelines are based on the best available evidence • the Department of Health asks NHS organisations to work towards implementing guidelines • compliance will be monitored by the Healthcare Commission

3. who should read the guidance? • all healthcare professionals • people with anaemia of CKD and their families and carers • patient support groups • commissioning organisations • service providers

4. a state in which the quality and/or quantity of circulating red blood cells is below normal how we define anaemia

5. haemoglobin cut offs in general populationdefining anaemia in people living at sea level

6. adverse effects of anaemia • reduced oxygen utilisation • increased cardiac output and left ventricular hypertrophy • reduced cognition, concentration and libido • reduced immune responsiveness

7. stages of CKD

8. how prevalent is anaemia of CKD?NHANES III data

9. renal anaemia • damaged kidney • impaired production of erythropoietin • reduced number of red blood cells • anaemia

10. other causes of anaemia in CKD chronic blood loss iron deficiency vitamin B12 or folate deficiency hypothyroidism chronic infection or inflammation hyperparathyroidism aluminium toxicity malignancy haemolysis bone marrow infiltration pure red cell aplasia

11. increase exercise capacity improve cognitive function regulate and/or prevent left ventricular hypertrophy prevent progression of renal disease reduce risk of hospitalisation decrease mortality key goals in managing anaemia of CKD

12. what the recommendations cover diagnosis of anaemia of CKD management of anaemia of CKD assessment and optimisation of erythropoiesis maintaining stable haemoglobin monitoring of ACKD treatment

13. diagnosis of anaemia of CKD in adults eGFR < 60ml/min/1.73m2 AND Hb ≤ 11 g/dl Treat and repeat Hb Yes No Non renal and haematinic deficiency excluded? No Consider other causes Yes No See initial management algorithm Patient on haemodialysis? See sections 1.2 & 1.3 Yes

14. initial management algorithm Ferritin < 500 µg/l? Yes No Ferritin < 200 µg/l? TSAT < 20% Or %HRC > 6% No Yes ESA (s.c.or i.v.) Yes – functional iron deficiency No Assess Hb If Hb increase < 1g/dl after 4 weeks, increase ESA using dose schedule ESA (s.c.or i.v.) and iron Hb > 9 g/dl Hb < 9 g/dl Continue monitoring Hb and iron status Hb < 11 g/dl i.v. iron Assess Hb at 6 weeks Hb > 11 g/dl

15. assess and optimise erythropoiesis • iron supplements should be given to maintain serum ferritin levels • ESA therapy is appropriate in iron-replete patients where existing comorbidities or prognosis do not negate its effect • benefits of ESA therapy include improved quality of life and physical functioning • there is no evidence to distinguish between ESAs in terms of efficacy

16. Hb maintenance algorithm (assumes ESA therapy and maintenance i.v. iron) Measure Hb Hb < 11 g/dl Hb 11–12 g/dl Hb 12–15 g/dl Hb > 15 g/dl ↑ ESA dose/ frequency as per schedule unless Hb rising by 1/g/dl/month. Check Hb as per Schedule. No change unless Hb rising by 1g/dl/month in which case consider ESA dose adjustment Consider stopping i.v. iron. ↓ ESA dose/frequency as per schedule unless Hb falling by more than 1g/dl/month. Check Hb as per schedule. Stop i.v. iron. Consider stopping ESA or halve dose/frequency. Check Hb in 2 weeks. If Hb is persistently low see poor response algorithm Ferritin < 200 µg/l?

17. iron status: not earlier than 1 week after i.v. iron routinely at intervals of between 4 weeks and 3 months haemoglobin: induction phase of ESAs every 2–4 weeks maintenance phase of ESAs every 1–3 months more actively after ESA dose adjustment monitor treatment

18. detecting ESA resistance target Hb levels not being reached despite appropriate treatment continuing need for high doses to maintain Hb other possible causes exclude other causes of anaemia check medicine concordance algorithm for poor response to ESAs ESA resistance aluminium toxicity – desferrioxamine test when aluminium toxicity suspected pure red cell aplasia (PRCA) – ESA-induced PRCA managed in accordance with best practice ESA resistance

19. implementation – some overarching principles • consider all age groups for anaemia management where appropriate • work across primary and secondary care to develop and share local protocols based on algorithms. Have clear pathways for specialist advice • develop training programmes to support patients and their carers

20. implementation – some overarching principles • consider having a ‘designated’ contact person(s) who can assume responsibility for a patient’s anaemia management • review local tendering arrangements and provision of ESAs and intravenous therapy in light of recommendations • raise awareness with relevant groups about the aims of ESA therapy • Put systems in place to review management of ESA therapy with patients after an agreed interval

22. costs and savings • ESAstreatment with ESAs should be offered to patients with anaemia of CKD who are likely to benefit in terms of quality of life and physical function. • determinant for treatment – age age alone should not be a determinant for the treatment of CKD

23. access tools online • costing tools • costing report • costing template • audit criteria • implementation advice • available from: www.nice.org.uk/CG039

24. access the guideline online • quick reference guide – a summary www.nice.org.uk/CG039quickrefguide • NICE guideline – all of the recommendations www.nice.org.uk/CG039niceguideline • full guideline – all of the evidence and rationale www.nice.org.uk/CG039fullguideline • information for the public – a plain English version www.nice.org.uk/CG039publicinfo