Anemia in

Chronic Kidney Disease

(Renal Anemia)

I Wayan Sudhana
 Manifestasi Klinis Penyakit
Ginjal Kronis (PGK)
• Hipertensi
• Gangguan elektrolit

• Anemia
• LVH
• PJK
• Hiperfosfatemia
• Nyeri Otot dan sendi
• Hiperparatiroidisme sekunder
• Odem

Journal of the American Medical Association. 2015

National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease
Penyebab Anemia Renal
Defisiensi
eritropoietin

Hyperparatiroidisme Defisiensi Besi

sekunder

Anemia

Inflamasi / Infeksi Hemoglobinopati

Masa hidup eritrosit

pendek
 Causes of Anaemia in CKD

Direct factors

Indirect factors

Kalantar-Zadeh et al. Adv Chronic Kidney Dis. 2009;16:143-51.

Med.CN/Nov/2016
 Benefits of Increasing Hb
in CKD Patients

• Decreased mortality risk

• Decreased hospitalization
• Improved quality of life
• Improved systemic Hemodynamics and Cardiac
function
• Regression of LVH
• Improved Cognitive function
 Anemia
Faktor risiko yang meningkatkan angka kematian (mortalitas)

4
Hazard-rasio untuk
semua penyebab

3
mortalitas

0
<11.0 >11.0–12.0 >12.0–13.0 >13.0

Rerata level Hb/Hemoglobin (g/dl)

Data dari 853 pasien pria dengan tingkat CKD 3-5 yang belum menjalani dialisis pada suatu pusat kesehatan selama
1990-2004 (rerata waktu follow-up 2.1 tahun)

Adjusted data from 853 male patients with CKD stages 3-5 not yet on dialysis at a single centre during
MED/RYN/May/2015 1990-2004 (mean follow-up 2.1 years). Reference was Hb >13.0g/dl
Kovesdy CP et al. Kidney Int 2006; 69: 560-564
LVH PREVALENCE AND RENAL FUNCTION

Patients (%)
80
70
60 n=246
50
40
30
20
10
0
50–75 25–50 <25 HD start
CrCl (ml/min)
The most important consequences of anemia is LVH development
Levin et al AJKD 1999
 Anemia dapat meningkatkan dan
mempercepat level keparahan CKD
100
N = 1658
10 Hgb Values
Anemia Prevalence (%)

80
15 11-12 g/dL
60 15
10-11 g/dL
<10 g/dL
8
40 17
62
9 8 43
20 5
20
14
0
<2 2-2.9 3-3.9 ≥4 Creatinine (mg/dL)
Chronic Kidney Disease (CKD) Progression

Hgb = hemoglobin.
Kausz et al. Dis Manage Health Outcomes. 2002;10:505-513.
 Mengenal Erythropoiesis
• Erythropoiesis  proses pembentukan sel darah merah
(erythrocytes) pada mamalia termasuk manusia.
Berkisar 3 sd 4 hari

BESI / Fe

Berkisar
10 sd 13
hari
Berkisar 21 hari
Berkisar 1 sd 2 hari

RBC = Red Blood Cell / Sel Darah Merah

Erythropoietin Iron

Besarab A.Nat Rev Nephrol 2010;6:699-710

The role of
IV iron
Reducing ESA doses & iron requirements
The Importance of Iron in CKD

Agarwal R. Hemodialysis International 2017; 21:S78–S82

KDIGO Clinical Practice Guideline for Anemia in CKD 2012
High Prevalence of Iron Deficiency in CKD:
Why?

Agarwal R. Hemodialysis International 2017; 21:S78–S82

 Status Besi pada
Pasien CKD

Cukup Defisiensi

Defisiensi Besi Fungsional Def Besi Absolute

Functional Iron
Deficiency
Low
Transferin
Adequate
Saturation Iron Store

Tsat < 20 % Ferritin > 100 ng/mL (pre-dialysis)

> 200 ng/mL (dialysis)

Functional iron deficiency: The present of adequate iron stores

but an inability to sufficiently mobilize this iron to the circulatory.

KDIGO Clinical Practice Guideline for Anemia in CKD 2012

Absolute Iron Deficiency
Low
Transferin
Low Iron
Saturation Store

Tsat < 20 % Ferritin < 100 ng/mL (pre-dialysis)

< 200 ng/mL (dialysis)

Both Transferin saturation and iron stores are low

KDIGO Clinical Practice Guideline for Anemia in CKD 2012

KDIGO Guideline 2012:
Chapter 2: Use of Iron to Treat
Anemia in CKD

KDIGO Clinical Practice Guideline for Anemia in CKD 2012

Oral or IV?

•Oral iron therapy is less effective for hemodialysis patient:

- poor absorption
- more blood loss
- poor compliance due to the side effect of
nausea
•Oral iron: CKD Non-Dialisis, CAPD
•Parentral iron administration is a better choice for this patient
•Side effecs: allergy, anaphylactic
•Contra indication: allergy, severe liver disease
Pemberian Besi Pertama Kali Lakukan Test Dose

IV drip Iron Sucrose

1 amp dalam 100 mL NaCl 0.9%

test dose : 25 mg (25 ml) drip dalam 15-30 menit

reaksi : (-)

Lanjutkan
(dalam 30 menit)
Iron Therapy
• Correction phase:
Iron sucrose 100 mg, diluted in 100 mls NaCL 0.9%, infusion
drips in 15-30 min
2x/week during HD. Estimated total dose 1 gram (10x)
May re-check after half dose (after 5x) administration
After 1 week re-check Iron status.

• Maintenance phase:
Iron sucrose 100 mg/2 week.
22
Lampiran 1
Algoritme
Terapi Besi

*Keterangan:
 Iron sucrose atau iron
dextran: bila dapat
ditoleransi, dosis 100 mg
diencerkan dengan 100
ml NaCl 0.9%, drip IV 15-
30 menit pada saat HD.
 Bila ST <20% dan FS
501-800 ng/ml lanjutkan
terapi ESA dan tunda
terapi besi, observasi
dalam satu bulan. Bila Hb
tidak naik, dapat
diberikan iron sucrose
atau iron dextran 100 mg
satu kali dalam 4 minggu,
observasi 3 bulan.
 Bila ST <20% dan FS
>800 ng/ml terapi besi
ditunda. Dicari penyebab
kemungkinan adanya
keadaan infeksi-
23
inflamasi.
E S A Therapy
ESA Therapy: When to
initiate?
• For adult CKD 5D patients, we suggest that ESA
therapy be used to avoid having the Hb
concentration fall below 9.0 g/dl by starting ESA
therapy when the hemoglobin is between 9.0–10.0
g/dl.
• Individualization of therapy is reasonable as some
patients may have improvements in quality of life
at higher Hb concentration and ESA therapy may be
started above 10.0 g/dl.

KDIGO 2012
 Terapi ESA

 Indikasi : Hb <10 g/dL atau Ht <30%

Dan penyebab anemia lainnya sudah disingkirkan

 Syarat : status besi cukup

ST 20 %
FS 100 ng/mL (pre-HD)
FS 200 ng/dL (HD)

 Kontraindikasi : Hipersensitivitas

Hati-hati : hipertensi berat, hiperkoagulasi

 Terapi ESA

1. Terapi ESA fase koreksi

2. Terapi ESA fase pemeliharaan

3. Bersamaan terapi ESA:Terapi pemeliharaan

status besi
KDIGO 2012:
• In general, we suggest that ESAs not be used to maintain Hb
concentration above 11.5 g/dl.
• Recommended target: 10-11.5 g/dL.
• In all adult patients, we recommend that ESAs not be used to
intentionally increase the Hb concentration above 13 g/dl.
• Reevaluate ESA dose if:
- The patient suffers an ESA related
adverse event.
- The patient has an acute or progressive illness
that may cause ESA hyporesponsiveness.

KDIGO 2012
ESA Therapy

KDIGO Clinical Practice Guideline for Anemia in CKD 2012

Kidney International (2016) 89, 971–973
ESA Therapy: IV atau SC ?

30
 SC – Meningkatkan Efisiensi
100

90
80
Mean dose (IU/kg/week)

70 32%
reduction in
60 dose

50
40
SC: Waktu
IV Paruh lebih panjang
SC
30
20
10
0

*Mean study duration = 82.3 days

 Rekomendasi Terapi ESA
Intravena atau Subkutan

Pre - Dialysis
Patients
Subcutaneous administration
Peritoneal
Dialysis
Patients

Intravenous administration 
Hemodialysis patients convenience
Patients Subcutaneous administration is better

Tsubaki Y et al. 2008 Japanese Society for Dialysis Therapy: Guidelines for Renal Anemia in Chronic Kidney Disease. Ther Apher Dial, Vol. 14, No. 3, 2010
Wish JB, Coyne DW. Use of Erhytropoiesis-Stimulating Agents in Patients with Anemia of Chronic Kidney Disease. Mayo Clinic Proc. 2007;82(11):1371-1380
33
34
TERIMA KASIH
35
 EPORON

Komposisi :

EPORON Mengandung Recombinant human erythropoietin alfa

2000 IU, 3000 IU, 4000 IU, 10.000 IU
Eporon 2000 dan 3000 masuk E-Katalog

Harga Paling Ekonomis

38