JC2011-09 Anemia in CKD - Dr Tuason

Review Article: An Update on the Controversies in Anemia Management in Chronic Kidney Disease: Lessons Learned and Lost: 

Review Article: An Update on the Controversies in Anemia Management in Chronic Kidney Disease: Lessons Learned and Lost Presenter: M. Suzanne Tuason, MD MPH Highland Sept 2011

Outline: 

Outline Introduction How is this relevant to me? Definitions Review Dilemma Review of Current Guidelines Review article of three recent clinical trials CREATE CHOIR TREAT Take home points

How is this relevant to me?: 

How is this relevant to me? From: Anemia in the Patient With CKD: Detection and Treatment. Accessed from http://www.medscape.org/viewarticle/533695_3

Definitions: 

Definitions Anemia: hemoglobin (Hgb) concentration below 13.0 g/dL for adult males and post-menopausal women & Hgb below 12.0 g/dL for premenopausal women Based on this criteria, nearly 90% of patients with a glomerular filtration rate <25 to 30 mL/min have anemia, many with Hgb levels below 10 g/dL Anemia of chronic kidney disease is due primarily to reduced production of erythropoietin by the kidney and to shortened red cell survival Kazmi, WH, et al. Anemia: An Early Complication of Chronic Renal Insufficiency. American Journal of Kidney Diseases 2001; 38:803.

Review Dilemma: 

Review Dilemma Link between cardiovascular disease and CKD became more evident Anemia identified as independent risk factor for developing left ventricular hypertrophy and heart failure Correction of anemia associated with improved quality of life and exercise tolerance Dilemma of optimal Hgb to improve quality of life without increasing cardiovascular events in CKD is still unclear From: Anemia in the Patient With CKD: Detection and Treatment. Accessed from http://www.medscape.org/viewarticle/533695_3

Slide 6: 

From: Mix, Christian, et al. Trial to Reduce Cardiovascular Events with Aranesp Therapy (TREAT): Evolving the management of cardiovascular risk in patients with chronic kidney disease. American Heart Journal Vol 149, No 3

Review Dilemma: 

Review Dilemma By 1989, recombinant human erythropoietin was approved by the United States Federal Drug Administration for the treatment of anemia of CKD & replaced the use of blood transfusions

Review of Current Guidelines: 

Review of Current Guidelines National Kidney Foundation (NKF) Dialysis Outcomes Quality Initiative (DOQI) guidelines for the anemia of CKD 2007 update recommends: Hgb target should generally be in the range of 11-12 g/dL in all patients with CKD Hgb target should not exceed 13 g/dL

Review of Current Guidelines: 

Review of Current Guidelines

Review article of three recent clinical trials: 

Review article of three recent clinical trials

CREATE: 

CREATE The Cardiovascular Risk Reduction by Early Anemia Treatment with Epoetin Beta trial Conclusion: Early complete correction of anemia did not reduce the risk of cardiovascular events among anemic patients with stage III-IV CKD

CHOIR: 

CHOIR Correction of Hemoglobin in Outcomes and Renal Insufficiency Conclusion: By May of 2005, the trial was terminated after recording 125 events in the higher Hgb group (13.5 g/dL ) versus 97 events in the lower Hgb group (11.3 g/dL ) Use of a target Hgb level of 13.5 is associated with an increased risk among patients with anemia of CKD

Slide 13: 

CHOIR: Enrollment & Outcomes

TREAT: 

TREAT Trial to Reduce Cardiovascular Events with Aranesp Therapy Conclusion: Both arms had similar risks of death or a cardiovascular event or end-stage renal disease, but there was an increased risk of fatal or nonfatal stroke with darbepoetin alfa

Discussion Questions: 

Discussion Questions Based on these trials, how would you use ESA in your own clinical practice to correct patient’s ACKD? What are the pros and cons for ESA use? What is your Hb goal? And Why?

Take Home Points: 

Take Home Points There is no clear benefit to normalizing Hgb in anemic patients with non-ESRD CKD, while in some cases showed harm Claims that “ESA use reduces the need for transfusions & improves quality of life and exercise tolerance” are unclear

References: 

References Anemia in the Patient With CKD: Detection and Treatment. Accessed from http://www.medscape.org/viewarticle/533695_3 Berns, Jeffrey. Anemia of chronic kidney diesease: Target hemoglobin/hematocrit for patients treated with erythropoietic agents. Uptodate May 2011. Eckhardt, Kai-Uwe. The CREATE trial-building the evidence. Nephrology Dialysis Transplantation. 2001. 16-18. Kazmi, WH, et al. Anemia: An Early Complication of Chronic Renal Insufficiency. American Journal of Kidney Diseases 2001; 38:803. Mix, Christian, et al. Trial to Reduce Cardiovascular Events with Aranesp Therapy (TREAT): Evolving the management of cardiovascular risk in patients with chronic kidney disease. American Heart Journal Vol 149, No 3. National Kidney Foundation Dialysis Outcomes Quality Initiative guidelines accessed from: http://www.kidney.org/professionals/KDOQI/guidelines_anemiaUP/guide1.htm Singh, Ajay, et al. Correction of Anemia with Epoetin Alfa in Chronic Kidney Disease. NEJM. Nov 16, 2006, 355;20. Teehan, Geoffrey, et al. Review Article: An Udate on the Controversies in Anemia Management in Chronic Kidney Disease: Lessons Learned and Lost. Anemia. Hindawi Publishing Corporation. Vol 2011: Accessed: from http://www.hindawi.com/journals/ane/2011/623673/