Mayo Clin Proc 81: 1575, 2006 7. HH Parving, et al. Kidney Int 69(11): 2057, 2006 8. CA Pollock, et al. Curr Opin Nephrol Hypertens 16(4): 359, 2007 9. M Murussi, et al. Diabet Med 24(10): 1136, 2007 10. AH Brantsma AH, et al. J Am Soc Nephrol 18(2): 637, 2007 11. AK Bello, et al. Nephrol Dial Transplant 22(6): 1619, 2007 12. S Linas. Clin J Am Soc Nephrol 3: S17, 2008 13. R Kunz, et al. Ann Intern Med 148: 30, 2008 14. IS Anand, et al. Circulation 120: 1577, 2009 15. K Matsushita, et al. Lancet 375: 2073, 2010 16. M Tonelli, et al. Ann Intern Med 154: 12, 2011 27 28 ANEMIA OF CHRONIC KIDNEY DISEASE by Anatole Besarab Introduction Anemia of CKD is defined as a Hb (hemoglobin) 20% and ferritin >100 ng/mL. In CKD Stage 5, the ferritin target is >200 ng/mL. Anemia of CKD usually begins during CKD Stage 3, ie, GFRs 20% but 100 ng/mL‡ CHr >32 pg/cell* † Therapeutic phlebotomy should not be undertaken, if the Hb is 13–18 g/dL, in the absence of ESA therapy, unless symptoms are present, eg, headache. ‡ Ferritin >800 ng/mL is not a contraindication to the use oral or parenteral iron; interpretation of clinical context and trend analysis of iron utilization is required, particularly with inflammation. *CHr (mean cellular hemoglobin content of reticulocytes); utility of this parameter has only been validated in hemodialysis-dependent ESRD patients. Evaluation CBC, absolute reticulocyte ct, TSAT, ferritin, vitamin B12, and folate levels. Always rule out other causes of anemia, eg, malignancy, inflammatory conditions, vitamin D deficiency, and iron deficiency before starting an ESA. Monitor iron parameters and CBC twice monthly after initiating therapy or until Hb stabilizes within the target range, then monthly. Use the absolute reticulocyte count to assess efficacy. Treatment Iron Ferrous sulfate: 200 mg elemental iron/24-h (alternative, ferrous fumarate) Iron dextran (INFeD®): 500–1000 mg iv infusions of low molecular wt iron dextran* Iron sucrose (Venofer®): 100–200 mg iv infusions in non-dialysis-dependent CKD Ferumoxytol (Feraheme®): 500–1000 mg iv in non-dialysis-dependent CKD *Iron dextran, iv, high molecular weight (Dexferrum®), is a distinct and separate product from INFeD® (see above). Erythropoiesis-Stimulating Agents (ESAs) Epoetin alfa (Procrit® or Epogen®): 10–40,000 Units, subcutaneously, q1–4 wk; begin therapy at Hb earn About Kidneys and Kidney Disease Know Your Kidneys Where are they? Your two kidneys are under the lower ribs in the back of the body above the waist. They are about the size of your fist. What do they do? Kidneys do a lot of important jobs. How important are the kidneys? You need at least one working kidney to live. Filter blood Kidneys keep what your body needs. They also get rid of what your body does not need. Keep the right amount of fluids in your body Too little fluid (dehydration) or too much can cause problems. Make hormones Kidneys make three important hormones. Hormones are chemical messengers. They signal the need to make red blood cells, they control blood pressure, and they help the body use vitamin D. 2 COPYRIGHT: NATIONAL KIDNEY FOUNDATION. DO NOT REPRODUCE. 3 e COPYRIGHT: NATIONAL KIDNEY FOUNDATION. DO NOT REPRODUCE. Healthy Kidneys 4 Every 30 minutes the kidneys filter all the blood in the body! The cleaned, filtered blood goes into the vein and back into circulation. COPYRIGHT: NATIONAL KIDNEY FOUNDATION. DO NOT REPRODUCE. Glomeruli can tell the difference between something you need and something you do not need. They filter out waste and extra fluid from the blood to make urine. 5 From the artery, blood flows into the kidneys and passes through millions of tiny filtering units called glomeruli (“glow-mareyou-lie”). Blood Cells Waste Tubes called ureters carry urine to the bladder. Urine is removed when you urinate (“pass water,” “go to the bathroom”). Enlarged glomerulus COPYRIGHT: NATIONAL KIDNEY FOUNDATION. DO NOT REPRODUCE. Kidney Problems Kidneys can get damaged. When kidneys are damaged, they cannot do all the things they should. This is called chronic kidney disease or CKD. Chronic kidney disease can affect anyone—young or old! 1 in 7 American adults has kidney disease — and most don’t know it. Chronic kidney disease doesn’t happen overnight! It happens slowly, and in stages. People with early kidney disease may not know anything is wrong. They cannot feel the damage before some kidney function is lost. 6 COPYRIGHT: NATIONAL KIDNEY FOUNDATION. DO NOT REPRODUCE. 7 Risk factors include: • Diabetes • High blood pressure • A family history of kidney failure • Being age 60 or older • African American, Hispanic, Asian, Pacific Islander, or American Indian • Obesity COPYRIGHT: NATIONAL KIDNEY FOUNDATION. DO NOT REPRODUCE. 8 There are 5 stages of chronic kidney disease. In each stage, the kidneys don’t work as well as the stage before. The stages are determined by the level of kidney function. Kidney function is measured by a test called glomerular filtration rate, or GFR. This number tells how well the glomeruli are filtering waste and extra fluid. A person can lose a lot of kidney function before feeling symptoms of kidney disease. When kidneys fail, a person needs a kidney transplant or dialysis to stay alive. A kidney transplant replaces a failed kidney with a healthy kidney from someone else.