Table 3 Management of anemia in patients with chronic kidney disease (CKD) [16, 29]
Intervention | Significance |
|---|---|
Identification and clinical evaluation | |
Screening | Patients with CKD should be evaluated for the presence of anemia once GFR reaches 60 mL/min. Kidney function (and Hb level) should be assessed in all patients with cardiovascular disease and diabetes. |
Hematological work-up | |
Hb | Determines severity of anemia. Hb is a more reliable surrogate marker than hematocrit. Dosages of erythropoietic agents are titrated to the absolute Hb value, taking into account the relative increase from the last dosage. |
Complete blood count (MCH, MCV, MCHC, white blood cell count, platelet count) | Information on: potential folate and vitamin B12 deficiency (high MCV indicative of macrocytosis); iron deficiency (low MCH indicative of hypochromia); and capacity of bone marrow function. |
Absolute reticulocyte count | Determination of proliferative activity |
Serum ferritin | Assessment of iron storage reserves (target, 200 ng/mL). There is little evidence to suggest treating patients with levels >500 ng/mL is worthwhile. |
TSAT or Hb content in reticulocytes | Iron balance and distribution (TSAT target > 20%). |
Treatment | |
Target risk factors | Progression of CKD can be delayed by tight control of blood pressure, blood glucose, and proteinuria. |
Stimulants of erythropoiesis | Recommended in anemic patients to maintain Hb levels between 11.0 g/dL and 12.0 g/dL. Monthly follow-up is required to ensure the regimen does not raise Hb >12 g/dL and/or induce hypertension. |
Iron | Oral iron preparations (FeSO4, Niferex, Proferrin, etc.) may be sufficient to raise iron stores, though monthly IV iron supplementation may be required to ensure optimal erythropoiesis in patients with iron-deficiency anemia. Iron gluconate or iron sucrose are safer than iron dextran, which has been associated with anaphylaxis. Emerging IV iron agents are designed to minimize free iron and oxidative stress; an emerging oral iron agent utilizes the heme iron receptor in the gut for enhanced absorption. |
Nutritional supplements | Oral supplementation of folate, pyridoxine and vitamin B12 (and other vitamins) is a rational choice in malnourished patients. |
Androgens | Not recommended. |