Renal association clinical practice guideline on Anaemia of Chronic Kidney Disease

Abstract

Anaemia is a commonly diagnosed complication among patients suffering with chronic kidney disease. If left untreated, it may affect patient quality of life. There are several causes for anaemia in this patient population. As the kidney function deteriorates, together with medications and dietary restrictions, patients may develop iron deficiency, resulting in reduction of iron supply to the bone marrow (which is the body organ responsible for the production of different blood elements). Chronic kidney disease patients may not be able to utilise their own body’s iron stores effectively and hence, many patients, particularly those receiving haemodialysis, may require additional iron treatment, usually provided by infusion.With further weakening of kidney function, patients with chronic kidney disease may need additional treatment with a substance called erythropoietin which drives the bone marrow to produce its own blood. This substance, which is naturally produced by the kidneys, becomes relatively deficient in patients with chronic kidney disease. Any patients will eventually require treatment with erythropoietin or similar products that are given by injection.Over the last few years, several iron and erythropoietin products have been licensed for treating anaemia in chronic kidney disease patients. In addition, several publications discussed the benefits of each treatment and possible risks associated with long term treatment. The current guidelines provide advice to health care professionals on how to screen chronic kidney disease patients for anaemia, which patients to investigate for other causes of anaemia, when and how to treat patients with different medications, how to ensure safe prescribing of treatment and how to diagnose and manage complications associated with anaemia and the drugs used for its treatment.

The role of iron repletion in adult iron deficiency anemia and other diseases

“…The Renal Association Guidelines recommend initiation of iron treatment for serum ferritin <100 μg/L and TSAT <20%. 62 New evidence from the 2019 PIVOTAL trial, however, indicates that proactively administered high-dose IV iron regimen is superior to reactively administered low-dose IV iron regimen in patients undergoing hemodialysis and it also decreases the necessary erythropoiesisstimulating agent (ESA) dosing. 63,64 There is also emerging literature that suggests higher ferritin levels can be tolerated before treatment initiation to reduce exogenous EPO requirements and improve anemia.…”

“…61 Use of ESAs increases utilization of iron stores for hematopoiesis; they should only be used after functional or absolute iron deficiency has been corrected. 62 The benefit of ESA initiation should be weighed against an increased risk of stroke. 62,70 8 | IRON TRE ATMENTS…”

“…62 The benefit of ESA initiation should be weighed against an increased risk of stroke. 62,70 8 | IRON TRE ATMENTS…”

Anaemia characteristic in end stage renal disease patients receiving haemodialysis at King Salman armed forced hospital in Tabuk, Saudi Arabia

“…6 Anaemia of CKD is usually normocytic normochromic and erythropoietin deficiency is to blame, However, uremicinduced inhibitors of erythropoiesis, shortened red blood cell (RBCs) lifespan and nutritional deficiencies, such as iron, folate and vitamin B12 may be contributors. [7][8][9][10] Anaemia could lead to deterioration in cardiac function increasing cardiovascular mortality and decreased cognition and mental acuity. Furthermore it can also be accompanied by debilitating symptoms, such as fatigue, weakness, lethargy, anorexia, and sleep disturbances.…”

Chapter 3 Demographic and Biochemistry Profile of Kidney Transplant Recipients in the UK in 2016:

“…The Renal Association Anaemia guidelines recommend 'achieving a population distribution centred on a mean of 11g/dl with a range of 10-12g/dl' [16] (equivalent to 110 g/L, range 100-120 g/L). However, many transplant patients with good graft function have haemoglobin concentrations .120 g/L without using erythropoiesis stimulating agents, therefore it is inappropriate to audit performance using the higher limit.…”