Management of anaemia in CKD

Management of anaemic in people with chronic kidney disease

• erythropoiesis-stimulating agent (ESA) therapy
  • should not be initiated in the presence of absolute iron deficiency without also managing the iron deficiency (1)
  • in people with functional iron deficiency, iron supplements should be given concurrently when initiating ESA therapy
  • when correcting anaemia of CKD, the dose and frequency of ESA should be:
    • determined by the duration of action and route of administration of the ESA
    • adjusted to keep the rate of Hb increase between 10 and 20 g/l/month
      
      
  • correction to normal levels of Hb with ESAs is not usually recommended in people with anaemia of CKD
    • typically maintain the aspirational Hb range between 100 and 120 g/litre for adults, young people and children aged 2 years and older, and between 95 and 115 g/litre for children younger than 2 years of age, reflecting the lower normal range in that age group
    • to keep the Hb level within the aspirational range, do not wait until Hb levels are outside the aspirational range before adjusting treatment (for example, take action when Hb levels are within 5 g/litre of the range's limits
  • increase or decrease ESA dose and/or frequency when Hb measurements fall outside action thresholds (usually below 105 g/litre or above 115 g/litre), or for example when the rate of change of Hb suggests an established trend (for example, greater than 10 g/ litre/month
    
    
  • ESA therapy and ACE inhibitors (or ARBs)
    • if ACE inhibitors (or ARBs) are used, an increase in ESA therapy should be considered
      
      
• iron therapy
  • if anaemia of CKD who are receiving ESAs iron therapy to achieve:
    • percentage of hypochromic red blood cells less than 6% (unless ferritin is greater than 800 micrograms/litre)
    • reticulocyte Hb count or equivalent tests above 29 pg (unless serum ferritin is greater than 800 micrograms/litre)
    • if the above tests are not available or the person has thalassaemia or thalassaemia trait, iron therapy should maintain transferrin saturation greater than 20% and serum ferritin level greater than 100 micrograms/litre (unless serum ferritin is greater than 800 micrograms/litre).
  • if receiving ESAs then should be given iron therapy to maintain:
  • percentage of hypochromic red blood cells less than 6% (unless serum ferritin is greater than 800 micrograms/litre)
  • reticulocyte Hb count or equivalent tests above 29 pg (unless serum ferritin is greater than 800 micrograms/litre)
  • transferrin saturation level above 20% and serum ferritin level above 100 micrograms/ litre (unless serum ferritin is greater than 800 micrograms/litre).
  • serum ferritin levels should not rise above 800 micrograms/l - the dose of iron should be reviewed when serum ferritin levels reach 500 micrograms/l
• nutritional supplements
  • supplements of vitamin C, folic acid or carnitine should not be prescribed as adjuvants specifically for the treatment of anaemia of CKD
• androgens should not be used to treat the anaemia
• clinically relevant hyperparathyroidism should be treated to improve the management of the anaemia.

Reference:

1. NICE (June 2015). Anaemia management in people with chronic kidney disease