Anaemia Management

Management of Anaemia for CKD Patients

Before learning how to carry out anaemia management, let us completely understand what anaemia (or anemia) is.

What is Anaemia?

Anaemia (or anemia) happens when there is a decreased number of circulating red blood cells in the body. It is the most common blood disorder in the general population. Symptoms can include headaches, chest pains, and pale skin.

Anaemia Management Details

Any patient with CKD presenting with anaemia:

• Should be referred to the local specialist renal department for full assessment and management. Clinical assessment should include an assessment of nutrition, general well-being and other possible causes for anaemia (e.g., occult blood loss).
• Blood pressure should also be checked and any other factor suggesting acute on chronic kidney disease – e.g., infection.
• The basic blood test investigations as outlined above should be sent (ensuring the results are available at the renal department).
• Management of anaemia should be considered in people with anaemia of CKD when the haemoglobin level is less than or equal to 11 g/dL (or 10 g/dL if under 2 years of age).
• In people with anaemia of CKD, treatment should aim to maintain stable haemoglobin levels between 10 and 12 g/dL for adults and children aged over 2 years and between 9.5 and 11.5 g/dL in children aged under 2 years.
• Treatment with erythropoiesis-stimulating agents should be offered to patients with anaemia of CKD who are likely to benefit in terms of quality of life and physical function.
• There are few studies comparing the efficacy of the various agents. One study reported that darbepoetin alfa weekly or every two weeks was more efficient in achieving target haemoglobin than those on weekly epoetin alfa, with fewer dose changes and minor vascular access complications.
• The time taken for erythropoietin treatment to be effective will depend on individual patient factors, such as degree of anaemia, degree of kidney disease and presence of other adverse factors – eg, iron deficiency.
• Contra-indications for erythropoietin treatment include uncontrolled hypertension.
• Potential side-effects of erythropoietin include increase in blood pressure or aggravation of hypertension, headache, increase in platelet count, influenza-like symptoms (may be reduced if intravenous injection is given over five minutes), thromboembolic events, pure red cell aplasia, hyperkalaemia and skin reactions.
• Increasing concerns over the risk of cardiovascular events have led to a reduction in the use of erythropoietin as a group in recent years.

There have been very rare reports of pure red cell aplasia in patients treated with epoetin alfa. The Commission on Human Medicines has advised that in patients developing epoetin alfa failure with a diagnosis of pure red cell aplasia, treatment with epoetin alfa must be discontinued and testing for erythropoietin antibodies considered.
Patients who develop pure red cell aplasia should not be switched to another erythropoietin.

Aluminium toxicity, concurrent infection or other inflammatory disease may impair the response to erythropoietin.

People receiving erythropoiesis-stimulating agent maintenance therapy should be given iron supplements (often requires intravenous iron) to keep their:

• Serum ferritin between 200 and 500 μg/L and either:
• The transferrin saturation level above 20% (unless ferritin is >800 μg/L); or
• Percentage hypochromic red cells less than 6% (unless ferritin is >800 μg/L).

In view of the concerns about the adverse effects of erythropoietin, other therapeutic options are being explored. These include hypoxia inducible factor-1 alpha (HIF-1α) stimulators. HIF-1α is known to be associated with oxygenation of the kidney tubule.

Clinically relevant hyperparathyroidism should be treated in order to improve anaemia management in patients with anaemia of CKD.

Where possible, blood transfusions should be avoided in patients in whom kidney transplant is a treatment option.

FIND OUT MORE