Anaemia Management in Patients with Chronic Kidney Disease (CKD)

Edward Appiah Boateng MSc. Advanced Nursing, University of Nottingham

Abstract Effects of ESAs

This poster discusses anaemia management in CKD patients, ESAs raise Hb levels and enhance quality of life in both
highlighting the use of erythropoiesis-stimulating agents (ESAs) and nondialysis and dialysis CKD patients.11,12
their effects. Steps to advance management in my hospital in
Ghana are then presented. They slow the progression of renal disease and delay the
need for renal replacement therapy.13,14
Introduction
Anaemia is a common and severe complication among CKD Yet, target Hb level of 12g/dl, or more, has no further
patients and contributes significantly to reduced quality of life. 1-3 improvement in patients quality of life. On the contrary, patients
risk of cardiovascular complication and death increases. 6,15,16
Its prevalence increases as kidney function decreases (fig. I) and, (fig. IV)
Figure II: I&U inappropriate and unnecessary transfusion; HSE handling and storage errors; ATR acute
unless treated, it contributes to the development of other transfusion reactions; HTR haemolytic transfusion reactions; TRALI transfusion-related acute lung injury;
PTP post transfusion purpura; TACO transfusion-associated circulatory overload; TAD transfusion-
complications, including left ventricular hypertrophy. 2,3,4 associated dyspnoea; TTI transfusion-transmitted infections; IBCT incorrect blood component transfused18

Treatment Mechanism of Action (ESAs)

In individuals with normal kidney function, hypoxia stimulates
Includes iron therapy, vitamin therapy, blood transfusion and the
the kidneys to produce erythropoietin which influences
use of ESAs. 3,4
erythropoiesis.9 (Fig. III)
Risks such as infections, iron overload and sensitisation against
However, progressive kidney damage impairs oxygen-sensing
future kidney transplant have made blood transfusion a last resort
and erythropoietin-producing functions of the kidney.7,10
for management.5,6 (Fig. II)

Thus, when administered, ESAs bind to and activate the EPO-

Epoetin alpha and other ESAs are safe and highly effective in the
R, enhancing the development of erythroid progenitor cells and,
treatment of anaemia related to conditions such as CKD, chronic
eventually, leading to increased production of erythrocytes. 6,8
inflammatory disorders and cancers.5,7,8
Fig. IV: Risk of all-cause mortality in the higher haemoglobin target group
compared with the lower haemoglobin target group (fixed effects analysis)20

Advancing Nursing Practice in Ghana

zz Early and frequent assessment of anaemia in CKD patients
Health insurance should cover ESAs
Avoiding blood transfusion as much as possible
Utilising research findings in clinical practice
Involving patients in their management through education
Monitoring Hb level closely once ESA therapy begins

Conclusion
Under treatment of anaemia as well as treatment beyond target Hb
levels poses a lot of risks for the CKD patient. Hence, appropriate
treatment should be given to such patients so as to attain the target
Fig. I: Prevalence of anaemia by CKD stage (WHO World Health Organisation; KDOQI Kidney
Disease Outcomes Quality Initiative.17 Figure III Erythropoietin pathway19 range of Hb and enhance their quality of life.

References
1. Frankenfield, D.L. and Johnson, C.A. (2002) Current management of anemia in adult hemodialysis patients with end-stage renal disease. American Journal of Health-System Pharmacy 59: 429-435 2. McClellan , W., Aronoff, S.L., Bolton, W.K., Hood, S., Lorber, D.L., Tang, K.L., Tse, T.F., Wasserman, B. and Leiserowitz, M. (2004) The prevalence of anemia in patients with chronic kidney disease. Current Medical Research and Opinion 20(9):1501-1510. 3. Nurko, S. (2006) Anemia in chronic kidney disease: causes, diagnosis, treatment. Cleveland Clinic
Journal of Medicine 73(3):289-297. 4. Gnanasekran, I. and Dimitrov, V. (2006) Primary care management of anemia in chronic kidney disease. Patient Care 40(5): 37-41. 5. Engert, A. (2000) Recombinant human erythropoietin as an alternative to blood transfusion in cancer-related anaemia. Disease Management and Health Outcomes 8(5):259-272. 6. Elliott, S., Pham, E. and Macdougall, I.C. (2008) Erythropoietins: a common mechanism of action. Experimental Hematology 36:1573-1584. 7. Erslev, A.J. and Besarab A. (1997) Erythropoietin in the
pathogenesis and treatment of the anemia of chronic renal failure. Kidney International 51:622-630. 8. Hodges, V.M., Rainey, S., Lappin, T.R. and Maxwell, A.P. (2007) Pathophysiology of anemia and erythrocytosis. Critical Reviews in Oncology/Hematology 64:139-158. 9. Eckardt, K.-U. (2001) Anaemia in end-stage renal disease: pathophysiological considerations. Nephrology, Dialysis, Transplantation 16(Suppl 7):2-8. 10. Lerma, E.V. and Stein, R. (2009) Anemia of chronic disease and renal failure [online]. Available at:
http://emedicine.medscape.com/article/1389854-overview [Accessed 5 February 2010]. 11. Johansen, K.L., Finkelstein, F.O., Revicki, D.A., Gitlin, M., Evans, C. and Mayne, T.J. (2010) Systematic review and meta-analysis of exercise tolerance and physical functioning in dialysis patients treated with erythropoiesis-stimulating agents. American Journal of Kidney Diseases 55(3): 535-548. 12. Gandra, S.R., Finkelstein, F.O., Bennett, A.V., Lewis, E.F., Brazg, T., and Martin, M.L. (2010) Impact of erythropoiesis-stimulating agents on energy and physical
function in nondialysis CKD patients with anemia: a systematic review. American Journal of Kidney Diseases 55(3): 519-534. 13. Gouva, C., Nikolopoulos, P., Ioannidis, J.P.A. and Siamopoulos, K.C. (2004) Treating anemia early in renal failure patients slows the decline of renal function: a randomized controlled trial. Kidney International 66:753-760. 14. Rossert, J., Froissart, M. and Jacquot, C. (2005) Anemia management and chronic renal failure progression. Kidney International 68(Suppl99):S76-S81. 15. National Institute for Health and Clinical
Excellence (2006) Anaemia management in people with chronic kidney disease (Guideline 39). NICE, London. 16. Locatelli, F., Covic, A., Eckardt, K.-U., Wiecek, A. and Vanholder, R. (2009) Anaemia management in patients with chronic kidney disease: a position statement by the Anaemia Working Group of European Renal Best Practice (ERBP). Nephrology, Dialysis, Transplantation 24:348-354. 17. McFarlane, S.I., Chen, S., Whaley-Connell, A.T., Sowers, J.R., Vassalotti, J.A., Salifu, M.O., Li, S., Wang, C., Bakris, G., McCullough, P.A., Collins, A.J.
and. Norris, K.C. (2008) Prevalence and associations of anemia of CKD: Kidney Early Evaluation Program (KEEP) and National Health and Nutrition Examination Survey (NHANES) 1999-2004. American Journal of Kidney Diseases 51(4 Suppl 2):S46-S55. 18. Taylor, C. (Ed.), Cohen, H., Mold, D., Jones, H. et al. on behalf of the Serious Hazards of Transfusion (SHOT) steering group. The 2008 Annual SHOT Report [online]. Available at: http://www.shotuk.org/wp-content/uploads/2010/03/SHOT-Report-2008.pdf [Accessed 25 April 2010]. 19. Anon. (2010)
Lifeblood: chronic kidney disease and anemia [online]. Available at: http://lifeblood.anaemiaworld.com/en/what-is-anemia/erythropoietin.html [Accessed 19 February 2010] 20. Phrommintikul, A., Haas, S.J., Elsik, M. and Krum, H. (2007) Mortality and target haemoglobin concentrations in anaemic patients with chronic kidney disease treated with erythropoietin: a meta-analysis. Lancet 369:381-388.