ANAEMIA IN KIDNEY DISEASE

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ANAEMIA IN KIDNEY DISEASE:

ANAEMIA IN KIDNEY DISEASE BY DR SACHIN N SOLANKE ASST. PROF. S.R.T.R. MEDICAL COLLEGE AMBAJOGAI

INTRODUCTION:

INTRODUCTION Anemia is frequent complication of CKD. Prevalence increases with diminishing renal function. (most reach need for dialysis in anemic state). Management changed after introduction of recombinant erythropoietin( rHuEpo ) in 1989. Anemia is one of the modifiable complications of CKD .

PATHOGENESIS:

PATHOGENESIS Decreased erythropoietin production. Decreased sensitivity of bone marrow erythroid cell to EPO due to uremic toxins. Decreased survival of RBC due to uremic toxins. GIT bleeding. Iron,folaten,B12 deficiency. Infection, inflammation. Blood loss during dialysis, routine blood test. Aluminum toxicity. Bone marrow fibrosis due to secondary hyperparathyroidism.

Sequence of CVS effect :

Sequence of CVS effect Low oxygen carrying capacity of RBC. Increased blood volume. Hypoxia induced peripheral vasodilatation. Increased cardiac output. LVH. Impaired cardiac contractility, systolic and diastolic dysfunction. Myocardial ischemia and CHF.

ERYTHROPOIESIS:

ERYTHROPOIESIS Production of EPO is stimulated by hypoxia. 90% EPO – kidney, 10%-liver. Other factors necessary for erythropoiesis are- A) Normal bone marrow B) Adequate iron, folate , B12.

CLINICAL FEATURES:

CLINICAL FEATURES Patient often not severely symptomatic despite degree of anemia. Tiredness, shortness of breath , palpitation etc. Morphology –normocytic normochromic . EPO-LOW.

CLINICAL APPROACH:

CLINICAL APPROACH Do not assume , anemia is caused by CKD only Exclude other causes of anemia by history taking , clinical examination , lab tests. Like –inadequate dialysis , poor nutrition , blood loss , infection , inflammation , hemolysis , Aluminium toxicity. Lab tests-CBC , PS, Stool for occult blood , iron store , ferritin , transferin saturation , chest x-ray etc. Other excluded / treated –attributed to CKD.

WHEN TO INVESTIGATE AND TREAT ANAEMIA IN CKD:

WHEN TO INVESTIGATE AND TREAT ANAEMIA IN CKD When estimated glomerular filtration rate ( eGFR ) of less than 60 ml/min/1.73m2 should trigger investigation into whether anaemia is due to CKD. Hb level falls to 11 g/dl or less or they develop symptoms attributable to anaemia (such as tiredness, shortness of breath, lethargy and palpitations)

TREATMENT:

TREATMENT WITH rHuEpo :- Important component in managing anemia of CKD. Each available rHuEpo are effective in achieving and maintaining target Hb levels. Aspect of administration may differ between short acting and long acting agents.

STARTING rHuEPO IN CKD WHY, WHEN, HOW :

STARTING rHuEPO IN CKD WHY, WHEN, HOW Why :- Improvement in appetite , physical activity. Improvement in quality of life. Improvement in exercise tolerance. Improvement in cardiac performance. Avoidance of blood transfusion and iron overload.

WHY, WHEN, HOW……………..:

WHY, WHEN, HOW…………….. When :- Patient is symptomatic of anemia. HB- < 10 gm%. Has normal iron store. Blood pressure is under control.

WHY, WHEN, HOW……………..:

WHY, WHEN, HOW…………….. How :- dose and frequency 50 iu /kg, two/three times a week. { > 175 IU/kg/week for haemodialysis population; > 125 IU/kg/week for peritoneal dialysis population; > 100 IU/kg/week for non-dialysis population . } dose and frequency can varied once a good response is achieved. Route of administration:- IV/SC. SC is preferred. adjusted to keep the rate of Hb increase between 1 and 2 g/dl/month

TARGET HB LEVEL:

TARGET HB LEVEL KDOQI GUIDELINE :-2006, 11-13 gm%. FDA:- Should not exceed 12 gm%. HB initially monitored weekly , dose adjustment made every 4 weekly. Once stable HB achieved , monitor 4 weekly to 3 monthly , or in between any intercurrent illness or symptomatic.

DOSE MODIFICATION:

DOSE MODIFICATION If HB level increases by >1gm%/2wks, then reduce dose of EPO by 25%. If HB level not increases by >1gm%/ mnth , then increase dose of EPO by 25%.

MANAGING IRON STORE:

MANAGING IRON STORE Iron status should be optimised before the initiation and during maintenance treatment with EPO. Iron status tests initially should be performed every monthly. Once stable or on HD ,3 monthly . Results of iron status tests , HB , rHuEPO dose should be interpreted together to guide iron therapy.

TARGET IRON THERAPY:

TARGET IRON THERAPY Maintain following indices of iron:- sr. ferritin :- 200 to 500ng/ml TSAT:- >20% (unless ferritin is greater than 800 micrograms/l). percentage hypochromic red cells less < 6% (unless ferritin is greater than 800 micrograms/l). Preferred route of administration IV in HD , (oral in PD,or not on dialysis.) Most patients will require 600–1000 mg of iron , in a single or divided dose depending on the preparation.

MANTAINANCE IRON THEREPY:

MANTAINANCE IRON THEREPY Once ferritin levels > 200 micrograms/l, and the percentage hypochromic red cells is < 6% or transferrin saturation is > 20%, people with anaemia of CKD who are receiving EPO should be given maintenance iron. dose required is 50–60 mg intravenous iron per week.

ADVERSE EVENTS OF rHuEPO:

ADVERSE EVENTS OF rHuEPO Hypertension,-30%. Hypertensive encephalopathy. Vascular access failure. Increase in pre dialysis CKP ,and potassium. Increases risk of stroke in DM type 2. L- Carnitine , vit -c , and androgens should be not be used routinely.

Epo resistance:

Epo resistance other causes of anaemia , such as intercurrent illness or chronic blood loss have been excluded Hb range is not achieved despite treatment with 300 IU/kg/week or more of subcutaneous epoetin or 450 IU/kg/week or more of intravenous epoetin or 1.5 micrograms/kg/week of darbepoetin .

MODIFIED EPO:

MODIFIED EPO Darbepoetin alfa :-dose 0.45 ug /kg , SC/IV /WK. OR 0.75 ug /kg/2 wks . CERA:- 50-100 ug / mnth , SC. Is not EPO , but it is EPO receptor activator. Above both specially in maintenance therapy.

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