Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Renal Anemia
Dr Tan Li Ping
MD (Canada), MPH (Malaya), FASN (USA)
Board Certified, Internal Medicine and Nephrology (USA)
Fellowship, Transplant Nephrology (USA)
Consultant Nephrologist
Oriental Melaka Straits Medical Centre
Agenda
Anemia in ESKD Population
** Part I
o Anemia and relation to Kidney Function
o Target Range for Hemoglobin in ESKD
o Risk when Hemoglobin range is exceeded
o Naturally occurring High Hemoglobin
** Part II
o Reasons for not reaching Hemoglobin target
KIDNEY FUNCTION AND ANEMIA
Normal Range of Hemoglobin
Hb distribution in women:
3000 13.3 0.9 g/dL
2000
Frequency
1500
1000
500
0
10 10.5 11 11.5 12 12.5 13 13.5 14 14.5 15 15.5 16 16.5 17 17.5 18
Hb level (g/dL)
N=40,000 (NHANES III, 1988-1994)
Dallman et al. Iron Nutrition in health and disease. John Libbey & Co, London, 1996
Hemoglobin Levels Correlate
with Renal Function
17 17
Males Females
15 15
13 13
11 11
Hb (g/dL)
9 9
7 7
0 10 20 30 40 50 0 10 20 30 40 50
10%
40%
7%
Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. KDIGO Clinical Practice
Guideline for Anemia in Chronic Kidney Disease. Kidney inter., Suppl. 2012; 2: 279335.
Mr. AB; 56yo Male; ESKD x2yrs
Hb 14-15
TREAT Trial
101 patients (5%) developed CVA in the darbapoeitin arm as compared to 53
patients (2.6%) in the placebo arm
There were also more venous thromboembolic events in the darbapoeitin group
(2% vs 1.1%, p=0.02) amd more arterial thromboembolic events (8.9% vs 7.1%,
p=0.04)
Do All ESKD Patients have Anemia?
91% of ESKD patient (total number 28,898 in
2013) reported via the NRR are on ESA (2013
MDTR)
Hb 14-15
** Part II
o Reasons for not reaching Hemoglobin target
WHAT ARE THE COMMON REASONS
FOR HEMOGLOBIN NOT TO BE IN THE
REQUIRED RANGE?
Case Example
58yo M ESKD Patient; HD x 3 / week for 3 months via L
AVF. DM2 / HTN
Which Agent:
Epoetin alfa OR beta: 50-100IU/kg x3/week
Darbopoeitin alfa: 0.45ug/Kg x1/week
PEG epoetin beta: 0.6mcg/kg every 2 weeks (maintain
1x/month)
Labs indicate: Hb 9.8 (Jan) -> 8.9 (Feb) -> 7.8 (March)
Labs indicate: Hb 9.8 (Jan) -> 8.9 (Feb) -> 8.8 (March)
Labs indicate: Hb 9.8 (Jan) -> 9.5 (Feb) -> 9.3 (March)
Current Meds
EPO 2000u sc x3/wk
CaCO3 500mg TDS
Rocaltrol 0.25mcg EOD
Amlodipine 10mg OD
Gliclazide 80mg BD
Simvastatin 20mg ON
Cardiprin 100mg OD
Details on Iron Administration
Oral iron
Fe sulphate 200mg 300mg tds (20% elemental iron)
Fe fumarate 200mg-400mg bd (33% elemental iron)
Recommended: 100mg elemental iron daily
Destruction of RBC
Hemolysis
Case Example
56yo M ESKD, HTN; HD x3/wk via L AVF. 70kg dry weight.
Current Meds
EPO 6000/4000/4000u sc x3/wk (increasing trend)
CaCO3 500mg TDS
Rocaltrol 0.25mcg OD
Amlodipine 10mg OD
Gliclazide 80mg BD
Simvastatin 20mg ON
Cardiprin 100mg OD
FeSO4 400mg BD / Vit B / Folic Acid
ESA Resistance
Case Example
56yo M ESKD, HTN; HD x3/wk via L AVF. 70kg dry weight.
Current Meds
EPO 6000/4000/4000u sc x3/wk (increasing trend)
CaCO3 500mg TDS
Rocaltrol 0.25mcg OD
Amlodipine 10mg OD PTH 256
Gliclazide 80mg BD Started on Cinacalcet
Simvastatin 20mg ON 2 month later, PTH 142 and
Cardiprin 100mg OD Hb increased to > 9
FeSO4 400mg BD / Vit B / Folic Acid
Agenda
Anemia in ESKD Population
** Part I
o Anemia and relation to Kidney Function
o Target Range for Hemoglobin in ESKD
o Risk when Hemoglobin range is exceeded
o Naturally occurring High Hemoglobin
** Part II
o Reasons for not reaching Hemoglobin target
THANK YOU