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A renalis anaemia kezel s nek speci lis szempontjai diabetes mellitusban s ischaemi s sz vbetegs gben

A renalis an

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A renalis anaemia kezel s nek speci lis szempontjai diabetes mellitusban s ischaemi s sz vbetegs gben

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    2. A renalis anémia kezelésének speciális szempontjai diabetes mellitusban és ischaemiás szívbetegségben Ladányi Erzsébet Fresenius Miskolci Nefrológiai Központ

    3. Esetbemutatás 1. G.B-né 37 éves no 17 éves korától ismert 1. tip. diab.mell. és hypertonia Ezen ido óta retinopathia, üvegtesti bevérzés, többszöri urosepsis, neuropathia, gastroparesis miatti hosp. Nefrol. gondozás 2004. óta Leletei - KN/kreat 9,2 / 121 – 11,4 / 123 mmol/umol/l - Hgb 11,3 – 9,8 – 8,4 gr/dl - vasháztartás, CRP, egyéb lab. norm. - GFR 79,7 – 73,0 – 70,4 ml/min, PU : 0,8 – 1,1 g/d - Ts.: 82 kg

    4. Esetbemutatás 1. G.B-né 37 éves no beteg Egy éve inzulinpumpa Vérzésforrás, occult vérzés kizárt Se-EPO szint : 3,79 IU/ml (norm.: 4-11 IU/ml) 6 hónapos NeoRecormon th. után hgb 11,4 g/dl, KN/kreat. 8,9/108 mmol-umol/l, GFR 73 ml/min/1,73 m2

    5. Esetbemutatás 2. B. A. 31 éves no 18 éve ismert 1. tip. diab.mell, súlyos micro - és macroangiopathias szövodményekkel, hypertoniás Nefrol. gondozás 2001. óta Leletei KN/kreat 5,6/80,5 – 9,1/131,0 mmol-umol/l, Hgb 11,2 – 11,7 – 10,5 – 9,3 g/dl Vasháztartási paraméterei, egyéb lab. leletek norm., vérzésforrás, occult vérzés kizárt Ts. 62 kg GFR 110 – 106 – 78,2 – 70,6 ml/min , PU = 1,0 g/d EPO szint meghatározás 2,35 IU/ml (n: 4 – 11 IU/ml) 7 hónapos EPO th. után Hgb 11,6 g/dl, KN/kreat. 9,3/113 mmol-umol/l, GFR 68,3 ml/min

    6. EPO kezelés indikációja Az idült vesebetegség bármely stádiumában és bármelyik vesepótló kezelési mód esetében , ha a hemoglobin koncentráció konzekvensen 11 g/dl (Htk<0,33) alatt van Renális anémia (eritropoietin hiány) valószínu: amennyiben a kivizsgálás során az anémia egyéb oka nem igazolódik és a glomerulus filtrációs ráta értéke 60 ml/perc/1.73m˛ alatti ...” Revised EBPG 2004.

    7. A végstádiumú veseelégtelenség okai Diabetes mellitus ( 30 - 40 % ! ) Vaszkuláris nefropátiák Glomerulopátiák Policisztás vesebetegségek Egyéb Az idült vesebetegek a diabetológiai és kardiológiai rendelokben is gyakran megfordulnak. Key message There are many risk factors for CKD. Diabetes is highlighted as a prevalent yet modifiable factor that is particularly relevant to the CKD Network audience.Key message There are many risk factors for CKD. Diabetes is highlighted as a prevalent yet modifiable factor that is particularly relevant to the CKD Network audience.

    9. A renális anémia gyakori szövodmény A Hgb szint a vesekárosodás progresszójával csökken Jungers et al. NDT 2002; 17 Diabeteses betegekben korábban jelenik meg a renális anémia Bosman et al. Diab. Care 2001; 24; Bilous. Acta Diabetol 2002; 39 Key message Further evidence highlighting the complication of CKD anaemia. The Jungers report describes regression analyses comparing Hb and creatinine clearance in 403 out-patients at the Necker Hospital Nephrology Department. The relation of decreasing renal function correlated with decreasing Hb in both males and females. The Bosman study involved 27 patients enrolled at the King’s College Hospital, London, who had type 1 diabetes with diabetic nephropathy and of those, 13 were anaemic. Among these patients, epoetin levels failed to increase in response to decreasing Hb, unlike the response seen in their non-anaemic counterparts. Key message Further evidence highlighting the complication of CKD anaemia. The Jungers report describes regression analyses comparing Hb and creatinine clearance in 403 out-patients at the Necker Hospital Nephrology Department. The relation of decreasing renal function correlated with decreasing Hb in both males and females. The Bosman study involved 27 patients enrolled at the King’s College Hospital, London, who had type 1 diabetes with diabetic nephropathy and of those, 13 were anaemic. Among these patients, epoetin levels failed to increase in response to decreasing Hb, unlike the response seen in their non-anaemic counterparts.

    10. Idült vesebetegség elofordulása 2 tip. diabetes mellitusban A 2T DM prevalenciája a CKD súlyosbodásával no NeoERICA adatok Key message Compared to the normal rate, diabetes is higher among patients with CKD and is worst among advanced CKD patients at stages 3 and above.Key message Compared to the normal rate, diabetes is higher among patients with CKD and is worst among advanced CKD patients at stages 3 and above.

    11. GFR és anémia kapcsolata diabéteszes nefropátiában

    12. Idült vesebetegség stádiumai Key message The focus on the predialysis population is central to the CKD Network concept. Since most complications accumulate before patients reach ESRD, it is important to begin therapeutic interventions as early as possible. For a non-nephrologist audience, it may also be useful to note that eGFR (mL/min/1.73m2) can be approximated to percentage of kidney function. Key message The focus on the predialysis population is central to the CKD Network concept. Since most complications accumulate before patients reach ESRD, it is important to begin therapeutic interventions as early as possible. For a non-nephrologist audience, it may also be useful to note that eGFR (mL/min/1.73m2) can be approximated to percentage of kidney function.

    13. Szérum kreatinin: félrevezeto lehet a funkcionális állapot megítélésében Key message A clear illustration of the inappropriateness of sCr as a sensitive indicator of kidney function.Key message A clear illustration of the inappropriateness of sCr as a sensitive indicator of kidney function.

    14. EPO kezelés indikációja Az idült vesebetegség bármely stádiumában és bármelyik vesepótló kezelési mód mellett, ha a hemoglobin koncentráció konzekvensen 11 g/dl (Htk<0,33) alatt van Renális anémia (eritropoietin hiány) valószínu: amennyiben a kivizsgálás során az anémia egyéb oka nem igazolódik és a glomerulus filtrációs ráta értéke 60 ml/perc/1.73m˛ alatti ...” ….Kivételesen indokolt lehet 60 – 90 ml/perc/1,73m2 GFR-nél……. Revised EBPG 2004.

    15. EPO kezelés célértékei „A cél- Hgb >11 g/dl (Htk > 33%)” „…az egész betegpopuláció 85 % -ának átlagos hemoglobin szintje 12-12,5 g/dl között legyen…” „Diabetesben perifériás érbetegség esetén nem javasolt 12 g/dl feletti Hgb szint „ ( haemorheológiai, viszkozitási viszonyok, plazma fibrinogén konc.,AGE termékek , vvt. deformitás + uraemia )

    16. Key message Dialysis is not the inevitable outcome for CKD patients. There are many hidden risk factors that if managed appropriately, can prevent or slow the progression of CKD.Key message Dialysis is not the inevitable outcome for CKD patients. There are many hidden risk factors that if managed appropriately, can prevent or slow the progression of CKD.

    17. Az anémia – a hypertonia mellett - az egyik legjelentosebb rizikótényezo az idült vesebetegség különbözo stádiumaiban jelentkezo progresszív balkamra hypertrophiában és a dializáltak cardiovascularis mortalitásában. A cardiovascularis károsodás már az idült vesebetegség korai stádiumaiban megkezdodik. Az idült veseelégtelenségben szenvedo betegek magas halálozásában 50 % körüli a cardiovasculáris betegség elofordulása

    18. Idült vesebetegség elofordulása a különbözo stádiumokban Key message CKD is highly prevalent with the greatest number of patients in early CKD stages. This population is large but under-recognised and has the most to gain from timely and appropriate management. Note also that the enormity of CKD prevalence means that optimal patient treatment will only be achieved with a concerted integrated effort between multiple disciplines.Key message CKD is highly prevalent with the greatest number of patients in early CKD stages. This population is large but under-recognised and has the most to gain from timely and appropriate management. Note also that the enormity of CKD prevalence means that optimal patient treatment will only be achieved with a concerted integrated effort between multiple disciplines.

    19. Az anémia lehetséges okai szívbetegségben CHF-ben károsodik a vese perfúziója 1 ( CHF betegek közel 50%-a szenved CKD-ban! ) Cytokin akt. (TNF-alfa, IL-6, ? EPO termelés, ? vasfelszívódás, ? EPO rez.) Profilaktikus aspirin kezelés okozta vashiány 2 Az ACE-gátlók EPO receptor down-regulációt okozó hatása 1,3 A krónikus vesebetegség (CKD) okozta relatív EPO termelés csökkenés 4 Csökkent csontveloi perfúzió 1

    20. Anémia és mortalitás összefüggése súlyos CHF betegekben

    22. „ Anaemia, Congestiv Heart Failure and Chronic Renal Failure : a lethal interaction „ Silverberg DS.

    23. Az anémia növeli a CHF mortalitást CHF - ben végzett 56 vizsgálat közül 54 (96,4%) igazolta: az anémia a CHF betegek fokozott mortalitásával jár SOLVD, ELITE, Val-Heft, ATLAS, IN-CHF, PRAISE, OPTIME, COPERNICUS, RENAISSANCE és OPTIMAL vizsgálatok Clin Nephrol. 2003 Jul;60 Suppl 1:S93-102. The cardio renal anemia syndrome: correcting anemia in patients with resistant congestive heart failure can improve both cardiac and renal function and reduce hospitalizations. Silverberg DS, Wexler D, Blum M, Iaina A. Department of Nephrology and Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel. donald@netvision.net.il Anemia (Hemoglobin of < 12 to 13 g/dl) is frequently encountered in patients with congestive heart failure (CHF). This anemia may be partly due to hemodilution, partly to the associated reduction in renal function, and partly to the use of ACE inhibitors and aspirin. However, there is evidence that CHF alone--through excessive cytokine production may also reduce the bone marrow and cause anemia. In several recent studies anemia has been found to be associated with a more severe degree of CHF, a higher rate of death, renal failure, hospitalization and evidence of malnutrition. In both uncontrolled and controlled studies correction of anemia with erythropoietin with or without the addition of i.v. iron has been attempted. The correction of anemia has been associated with a marked improvement in New York Heart Association (NYHA) functional cardiac class and Left Ventricular Ejection Fraction, a marked reduction in the need for hospitalization and high dose oral and i.v. diuretics, and an improvement in exercise capacity, peak exercise oxygen utilization and quality of life. The serum creatinine, which had been increasing steadily before treatment, stabilized with the correction of anemia. All this suggests that control of anemia in CHF could become a valuable addition to the therapeutic armamentarium of CHF and might also play a major role in the prevention of progressive renal failure. Publication Types: Review PMID: 12940539 [PubMed - indexed for MEDLINE] Int J Cardiol. 2004 Jul;96(1):79-87. Prevalence of anemia in patients admitted to hospital with a primary diagnosis of congestive heart failure. Wexler D, Silverberg D, Sheps D, Blum M, Keren G, Iaina A, Schwartz D. Cardiology and Heart Failure Unit, Tel Aviv Souraski Medical Center, Weizman 6, 64239 Tel Aviv, Israel. OBJECTIVES: To find the prevalence of anemia in patients hospitalized with the primary diagnosis of congestive heart failure (CHF). BACKGROUND: There is growing evidence that anemia is common in CHF and may contribute to the high morbidity and mortality associated with this condition. However, there is considerable disagreement about the prevalence of anemia in this condition. METHODS: In 338 consecutive patients who were admitted to the medical wards with a primary diagnosis of CHF we extracted from the charts the hemoglobin (Hb), serum creatinine, age, sex, New York Heart Association (NYHA) functional class, presence of smoking, diabetes, hypertension, hyperlipidemia and the primary cardiac etiology of the CHF. Anemia was considered to be present when the Hb on admission was <12 g/dl. RESULTS: All the patients were NYHA functional class III-IV. One hundred seventy seven (52.4%) of the 338 patients had a Hb on admission that was <12 g/dl. The mean Hb for the entire group was 12.0+/-1.8 g/dl. One hundred three (51.0%) of the 202 males were anemic compared to 74 (54.4%) of the 136 women. The mean serum creatinine was 1.7+/-1.1 mg/dl. The prevalence of renal insufficiency (serum creatinine >1.5 mg%) was 47.6%. There was a negative correlation between the level of serum creatinine and Hb (r=-0.294) P<0.00001. Of the 177 patients who were anemic, most of 114 (64.4%) had a serum creatinine >1.5 mg/dl. CONCLUSIONS: Anemia is a common finding in patients hospitalized with CHF and most anemic CHF patients have some degree of renal insufficiency. In view of the negative effect of anemia on cardiac function, it may be a common and important contributor to the mortality and morbidity of CHF in these patients. PMID: 15203265 [PubMed - indexed for MEDLINE] Full text in library J Nephrol. 2004 Nov-Dec;17(6):749-61. The role of anemia in the progression of congestive heart failure. Is there a place for erythropoietin and intravenous iron? Silverberg DS, Wexler D, Iaina A. Department of Nephrology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel. donald@netvision.net.il Anemia is found in about one-third of all cases of congestive heart failure (CHF). The most likely common cause is chronic kidney insufficiency (CKI), which is present in about half of all CHF cases. The CKI is likely to be due to the renal vasoconstriction that often accompanies CHF and can cause long-standing renal ischemia. This reduces the amount of erythropoietin (EPO) produced in the kidney and leads to anemia. However, anemia can occur in CHF without CKI and is likely to be due to excessive cytokine production (for example, tumor necrosis factor-alfa (TNF-alfa) and interleukin-6 (IL-6)), which is common in CHF and can cause reduced EPO secretion, interference with EPO activity in the bone marrow and reduced iron supply to the bone marrow. The anemia itself can worsen cardiac function, both because it causes cardiac stress through tachycardia and increased stroke volume, and because it can cause a reduced renal blood flow and fluid retention, adding further stress to the heart. Long-standing anemia of any cause can cause left ventricular hypertrophy (LVH), which can lead to cardiac cell death through apoptosis and worsen the CHF. Therefore, a vicious circle is set up wherein CHF causes anemia, and the anemia causes more CHF and both damage the kidneys worsening the anemia and the CHF further. We have termed this vicious circle the cardio renal anemia (CRA) syndrome. Patients with CHF who are anemic are often resistant to all CHF medications resulting in being hospitalized repeatedly. Many studies also demonstrate that these patients die more rapidly than their non-anemic counterparts do. In addition, they have a more rapid deterioration in their renal function and can end up on dialysis. There is now evidence from both uncontrolled and controlled studies that early correction of the CHF anemia with subcutaneous EPO and intravenous (i.v.) iron improves shortness of breath and fatigue, cardiac function, renal function and exercise capability, dramatically reducing the need for hospitalization. For these reasons, it is not surprising that quality of life has also been shown to improve. As both CHF and end-stage renal disease (ESRD) are rapidly increasing, the possibility that these twin conditions can be improved by the adequate treatment of anemia offers new hope for slowing the progression of both conditions. Publication Types: Review PMID: 15593047 [PubMed - indexed for MEDLINE] Clin Nephrol. 2003 Jul;60 Suppl 1:S93-102. The cardio renal anemia syndrome: correcting anemia in patients with resistant congestive heart failure can improve both cardiac and renal function and reduce hospitalizations. Silverberg DS, Wexler D, Blum M, Iaina A. Department of Nephrology and Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel. donald@netvision.net.il Anemia (Hemoglobin of < 12 to 13 g/dl) is frequently encountered in patients with congestive heart failure (CHF). This anemia may be partly due to hemodilution, partly to the associated reduction in renal function, and partly to the use of ACE inhibitors and aspirin. However, there is evidence that CHF alone--through excessive cytokine production may also reduce the bone marrow and cause anemia. In several recent studies anemia has been found to be associated with a more severe degree of CHF, a higher rate of death, renal failure, hospitalization and evidence of malnutrition. In both uncontrolled and controlled studies correction of anemia with erythropoietin with or without the addition of i.v. iron has been attempted. The correction of anemia has been associated with a marked improvement in New York Heart Association (NYHA) functional cardiac class and Left Ventricular Ejection Fraction, a marked reduction in the need for hospitalization and high dose oral and i.v. diuretics, and an improvement in exercise capacity, peak exercise oxygen utilization and quality of life. The serum creatinine, which had been increasing steadily before treatment, stabilized with the correction of anemia. All this suggests that control of anemia in CHF could become a valuable addition to the therapeutic armamentarium of CHF and might also play a major role in the prevention of progressive renal failure. Publication Types: Review PMID: 12940539 [PubMed - indexed for MEDLINE] Int J Cardiol. 2004 Jul;96(1):79-87. Prevalence of anemia in patients admitted to hospital with a primary diagnosis of congestive heart failure. Wexler D, Silverberg D, Sheps D, Blum M, Keren G, Iaina A, Schwartz D. Cardiology and Heart Failure Unit, Tel Aviv Souraski Medical Center, Weizman 6, 64239 Tel Aviv, Israel. OBJECTIVES: To find the prevalence of anemia in patients hospitalized with the primary diagnosis of congestive heart failure (CHF). BACKGROUND: There is growing evidence that anemia is common in CHF and may contribute to the high morbidity and mortality associated with this condition. However, there is considerable disagreement about the prevalence of anemia in this condition. METHODS: In 338 consecutive patients who were admitted to the medical wards with a primary diagnosis of CHF we extracted from the charts the hemoglobin (Hb), serum creatinine, age, sex, New York Heart Association (NYHA) functional class, presence of smoking, diabetes, hypertension, hyperlipidemia and the primary cardiac etiology of the CHF. Anemia was considered to be present when the Hb on admission was <12 g/dl. RESULTS: All the patients were NYHA functional class III-IV. One hundred seventy seven (52.4%) of the 338 patients had a Hb on admission that was <12 g/dl. The mean Hb for the entire group was 12.0+/-1.8 g/dl. One hundred three (51.0%) of the 202 males were anemic compared to 74 (54.4%) of the 136 women. The mean serum creatinine was 1.7+/-1.1 mg/dl. The prevalence of renal insufficiency (serum creatinine >1.5 mg%) was 47.6%. There was a negative correlation between the level of serum creatinine and Hb (r=-0.294) P<0.00001. Of the 177 patients who were anemic, most of 114 (64.4%) had a serum creatinine >1.5 mg/dl. CONCLUSIONS: Anemia is a common finding in patients hospitalized with CHF and most anemic CHF patients have some degree of renal insufficiency. In view of the negative effect of anemia on cardiac function, it may be a common and important contributor to the mortality and morbidity of CHF in these patients. PMID: 15203265 [PubMed - indexed for MEDLINE] Full text in library J Nephrol. 2004 Nov-Dec;17(6):749-61. The role of anemia in the progression of congestive heart failure. Is there a place for erythropoietin and intravenous iron? Silverberg DS, Wexler D, Iaina A. Department of Nephrology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel. donald@netvision.net.il Anemia is found in about one-third of all cases of congestive heart failure (CHF). The most likely common cause is chronic kidney insufficiency (CKI), which is present in about half of all CHF cases. The CKI is likely to be due to the renal vasoconstriction that often accompanies CHF and can cause long-standing renal ischemia. This reduces the amount of erythropoietin (EPO) produced in the kidney and leads to anemia. However, anemia can occur in CHF without CKI and is likely to be due to excessive cytokine production (for example, tumor necrosis factor-alfa (TNF-alfa) and interleukin-6 (IL-6)), which is common in CHF and can cause reduced EPO secretion, interference with EPO activity in the bone marrow and reduced iron supply to the bone marrow. The anemia itself can worsen cardiac function, both because it causes cardiac stress through tachycardia and increased stroke volume, and because it can cause a reduced renal blood flow and fluid retention, adding further stress to the heart. Long-standing anemia of any cause can cause left ventricular hypertrophy (LVH), which can lead to cardiac cell death through apoptosis and worsen the CHF. Therefore, a vicious circle is set up wherein CHF causes anemia, and the anemia causes more CHF and both damage the kidneys worsening the anemia and the CHF further. We have termed this vicious circle the cardio renal anemia (CRA) syndrome. Patients with CHF who are anemic are often resistant to all CHF medications resulting in being hospitalized repeatedly. Many studies also demonstrate that these patients die more rapidly than their non-anemic counterparts do. In addition, they have a more rapid deterioration in their renal function and can end up on dialysis. There is now evidence from both uncontrolled and controlled studies that early correction of the CHF anemia with subcutaneous EPO and intravenous (i.v.) iron improves shortness of breath and fatigue, cardiac function, renal function and exercise capability, dramatically reducing the need for hospitalization. For these reasons, it is not surprising that quality of life has also been shown to improve. As both CHF and end-stage renal disease (ESRD) are rapidly increasing, the possibility that these twin conditions can be improved by the adequate treatment of anemia offers new hope for slowing the progression of both conditions. Publication Types: Review PMID: 15593047 [PubMed - indexed for MEDLINE]

    24. Idült vesebetegség , CVD betegségek és összmortalitás összefüggései Key message CKD patients have a higher risk for poor outcomes compared to those with normal eGFR. Data was accumulated from four community-based longitudinal cohort studies carried out in the USA between 1987 and 1993: Atherosclerosis Risk in Communities Study, the Cardiovascular Health Study (CHS), the Framingham Heart Study (FHS) and the Framingham Offspring Study (Offspring). Analyses from 22,634 patients were included with a mean follow-up time of 99 months. CV events refers to myocardial infarction or fatal coronary heart disease.Key message CKD patients have a higher risk for poor outcomes compared to those with normal eGFR. Data was accumulated from four community-based longitudinal cohort studies carried out in the USA between 1987 and 1993: Atherosclerosis Risk in Communities Study, the Cardiovascular Health Study (CHS), the Framingham Heart Study (FHS) and the Framingham Offspring Study (Offspring). Analyses from 22,634 patients were included with a mean follow-up time of 99 months. CV events refers to myocardial infarction or fatal coronary heart disease.

    28. Anémia kezelésének hatása: NYHA See slide 17.See slide 17.

    29. A renális anémia kezelése hatásai

    30. Predilalízis EPO kezelés hatása a CVD kialakulásának kockázatára Nephrol Dial Transplant. 2003 Jun;18 Suppl 2:ii2-6. Anaemia management prior to dialysis: cardiovascular and cost-benefit observations. Collins AJ. University of Minnesota, Minneapolis, Minnesota 55404, USA. acollins@nephrology.org Anaemia correction with recombinant human erythropoietin (rh-EPO, epoetin) in end-stage renal disease (ESRD) patients has been associated with improved survival and quality of life, as well as lower overall treatment costs. Few studies, however, have evaluated the benefits of epoetin treatment given to chronic kidney disease (CKD) patients during the pre-dialysis period. A retrospective study of 89 193 incident haemodialysis patients in the Medicare system (age > or =67 years) assessed consistency of epoetin treatment before the start of dialysis and the outcome of patients once they reached ESRD. Patients were grouped according to consistency of epoetin treatment based on the available months of treatment in the 2-year period before starting dialysis. Only 15.6% of patients in the study received any epoetin before the initiation of dialysis. Patients who received no or infrequent epoetin (i.e. received epoetin in <50% of possible months) had a significantly higher relative risk of cardiac disease and death than patients treated with epoetin more frequently. Patients who received no or infrequent epoetin also had significantly higher rates of hospitalization and overall treatment costs at the time of initial dialysis. These findings suggest that early epoetin treatment warrants further investigation in prospective, randomized studies. In summary, it is evident that the care of CKD patients can be improved. Evidence suggests that timely initiation of epoetin treatment to correct renal anaemia appears to be associated with improved survival of ESRD patients in the first year after start of dialysis and reduced costs of treatment. Publication Types: Review PMID: 12819293 [PubMed - indexed for MEDLINE] Nephrol Dial Transplant. 2003 Jun;18 Suppl 2:ii2-6. Anaemia management prior to dialysis: cardiovascular and cost-benefit observations. Collins AJ. University of Minnesota, Minneapolis, Minnesota 55404, USA. acollins@nephrology.org Anaemia correction with recombinant human erythropoietin (rh-EPO, epoetin) in end-stage renal disease (ESRD) patients has been associated with improved survival and quality of life, as well as lower overall treatment costs. Few studies, however, have evaluated the benefits of epoetin treatment given to chronic kidney disease (CKD) patients during the pre-dialysis period. A retrospective study of 89 193 incident haemodialysis patients in the Medicare system (age > or =67 years) assessed consistency of epoetin treatment before the start of dialysis and the outcome of patients once they reached ESRD. Patients were grouped according to consistency of epoetin treatment based on the available months of treatment in the 2-year period before starting dialysis. Only 15.6% of patients in the study received any epoetin before the initiation of dialysis. Patients who received no or infrequent epoetin (i.e. received epoetin in <50% of possible months) had a significantly higher relative risk of cardiac disease and death than patients treated with epoetin more frequently. Patients who received no or infrequent epoetin also had significantly higher rates of hospitalization and overall treatment costs at the time of initial dialysis. These findings suggest that early epoetin treatment warrants further investigation in prospective, randomized studies. In summary, it is evident that the care of CKD patients can be improved. Evidence suggests that timely initiation of epoetin treatment to correct renal anaemia appears to be associated with improved survival of ESRD patients in the first year after start of dialysis and reduced costs of treatment. Publication Types: Review PMID: 12819293 [PubMed - indexed for MEDLINE]

    31. Normalis Hgb konc. dializált betegekben

    32. A renális anémia EPO kezelésének hatása a betegek kardiális állapotára Csökken a bal kamra izomtömeg és javul a balkamra funkció Silverberg DS et al. J. Nephrol 2004;17 Hayashi T et al. AJKD 2000 .35(2) Hampl H et al.JASN 2005;25 Javul a betegek fizikai terhelhetosége Mancini DM et al. Circulation 2003.21 Javul az életminoség McMahon LP et al. NDT 2000. 15(9) Csökken a szívelégtelenség miatti hospitalizációk száma Silverberg DS et al. Kidney Blood Press Res 2005;28 Silverberg DS et al. JACC 2000;35

    33. A renális anémia EPO kezelésének célértékei Cél hgb: >11 g/dl a betegek 85 %-ánál Súlyos cardiovascularis betegségben kerülni kell a teljes korrekciót, nem javasolt a hgb > 12 g/dl feletti érték , hacsak a súlyos tünetek (pl. angina pect.) ezt nem indokolják. Optimális Hgb szint ezen betegeknél 11,0 – 12,0 g/dl között (A evidenciaszint) MANET 2005. Revised EBPG 2004.

    34. Összefoglalás A CHF gyakran szövodik anémiával Az anémia a CHF önálló rizikófaktora Az anémia korrekciója EPO-val javítja a balkamra funkciót, az életminoséget, a terhelhetoséget és csökkenti a hosp.számát Az anémia részleges korrekciója javítja a dializáltak túlélését, de nem normalizálja a szívelváltozásokat Az anémia már predialízis stádiumban történo kezelése mérlegelendo ( eGFR, szoros vérkép kontroll) Idült vesebetegségben, diabetes és szívbetegség esetén korábban, más célértékekkel és nagy körültekintéssel kell elkezdeni a renalis anaemia kezelését.

    35. „Az az igazság, hogy az orvostudományban nincsenek külön szakterületek, hiszen ahhoz, hogy valaki teljes egészében ismerje az összes jelentos megbetegedést, tisztában kell lennie ezek megnyilvánulási formáival számos szerv esetében.” William Osler The Army Surgeon (A katonaorvos) Medical News, Philadelphia 1894;64:318

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