Recurrent Anaemia

in ESRD

Dr. W. Ahmad Syahril

IIUM
• HD 1, 3 , 5 since 2011
• Via Left BCF
• Qb 350. IDWG 2.5-3.0 kg
• TDW achieved
• kT/V 1.93
• Medications :
• Felodipine 10mg ON
• Recormon 6000 U/ week
• BCO / Folate
• CaCO3 2gm tds
• 1-alfacalcidol 2mcg EOD
• January 2015 – OGDS and Colonoscopy
Anemia - in CKD 5D
Case Reports
Lower Gastrointestinal Bleeding in Chronic Hemodialysis Patients
 Anaemia – Initial evaluation

• Anaemia of CKD – hypoproliferative,

normochromic and normocytic

• Macrocytosis : folate, B12 deficiencies,

alcohol

• Hypochromic / microcytic: iron deficiency,

haemoglobinopathies , chronic blood loss
 Anaemia evaluation

• Ferritin and TSAT

• Percentage of hypochromic red cells
• CHr ( Retics Hb content ) monitoring

• Other test: hs‐CRP

 ERBP position statement on the
KDIGO anaemia guideline

• Different cut‐off for ferritin and TSAT

• No previous iron treatment:

• Ferritin < 300 ng/ml
• TSAT < 25%

• Post Iron treatment:

• Ferritin 500 ng/ml and TSAT 30% should not be
intentionally exceeded
NDT (2013) 28: 1346‐1359
 IDA in CKD - causes
• Decreased dietary intake
• • Decreased GI absorption
• • Increased inflammation
• • Frequent blood testing
• • Use of phosphate binders
• • Procedures done & haemodialysis Rx itself
• • Treatments with ESAs (?)
Erythropoietin
EPO Disadvantages
Erythropoietin abuse
What Does the guidelines say ?
The New US FDA ESA label: 12/11
For patients with CKD not on dialysis:

• • Consider initiating ESA treatment only when the

hemoglobin level is less than 10 g/dL and the following
considerations apply:
•  The rate of hemoglobin decline indicates the likelihood of
requiring a red blood cell transfusion; and
•  Reducing the risk of alloimmunization and/or other red
blood cell transfusion-related risks is a goal.
•  If the hemoglobin level exceeds 10 g/dL, reduce or
interrupt the dose of ESA and use the lowest dose of ESA
sufficient to reduce the need for red blood cell transfusions.
• The New KDIGO Anemia Guidelines
(KI supplement Aug 2012) :

• 3.1: Address all correctable causes of anemia (including iron deficiency

and inflammatory states) prior to initiation of ESA therapy. (Not Graded)
• 3.2: In initiating and maintaining ESA therapy, we recommend balancing
the potential benefits of reducing blood transfusions and anemia-related
symptoms against the risks of harm in individual patients (e.g., stroke,
vascular access loss, hypertension). (1B)
• We recommend using ESA therapy with great caution, if at all, in CKD
patients with active malignancy—in particular when cure is the
anticipated outcome—(1B), a history of stroke (1B), or a history of
malignancy (2C).

• 3.4.1: For adult CKD ND patients with Hb concentration >10.0 g/dl

• (> 100 g/l), we suggest that ESA therapy not be initiated. (2D)
• 3.4.2: For adult CKD ND patients with Hb concentration 10.0
g/dl (100 g/l) we suggest that the decision whether to
initiate ESA therapy be individualized based on the rate of
fall of Hb concentration, prior response to iron therapy, the
risk of needing a transfusion, the risks related to ESA therapy
and the presence of symptoms attributable to anemia. (2C)

• 3.4.3: For adult CKD 5D patients, we suggest that ESA

therapy be used to avoid having the Hb concentration fall
below 9.0 g/dl (90 g/l) by starting ESA therapy when the
hemoglobin is between 9.0– 10.0 g/dl (90–100 g/l). (2B)
• 3.4.4: 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 (100 g/l). (Not Graded)
• What is the target Hb ??
Hb targets
Relatively Newer Agents