Anemia Pada Pasien Dialisis

(CKD Stage 5D)

Dr Fredie Irijanto, PhD, SpPD-KGH, FINASIM

Objectives

 ANAEMIA OF CKD CAUSES & CONSEQUENCES

 K-DIGO GUIDELINES 2012 , European best practice

guidelines statement 2013 , data from DOPS 2013
1. Diagnosis and evaluation of anemia in CKD
2. Use of iron
3. Use of Erythrocyte stimulating agents ESAs and other agents
4. evaluation and correction of persistent failure to reach or maintain
intended haemoglobin concentration
5. evaluation of pure red blood cell aplasia
6. Red cell transfusion to treat anemia in CKD
Latar Belakang

 Anemia merupakan komplikasi yang umum terjadi

 CKD stage 3 - 5D
 Outcome pasien CKD dengan anemia tidak baik

mortalitas
LVH
hospital
gangguan kognitif
cerebrovaskuler
cardiovaskuler
progresifitas penyakit ginjal
penurunan QOL
Latar Belakang

 Etiologi anemia pada pasien dialisis

Multifaktorial
Defisiensi EPO
Defisiensi zat besi
malnutrisi
uremikum
infeksi
inflamasi
melena ec stress ulcer
EPO resisten
dll
Patofisiologi

 Sistem Eritropoietik

Hipoksia menstimulasi produksi eritrosit melalui interaksi sistem HIF

(Hipoksia Inducible Factor)

Pada keadaan hipoksia, sub unit Alfa dan Beta dari HIF masuk ke dalam sel,
ke inti sel yang mengandung DNA sequence yang disebut hipoxia respond
elements.

hal di atas yang menyebabkan stimulasi produksi eritroprotein (EPO) di sel

jukstaglomerular di cortex ginjal.

Eritroprotein inilah merupakan hormon yang mengikat reseptor sel-sel

sumsum tulang untuk memproduksi eritrosit.
Patofisiologi

 EPO diberikan bila Hb 9-10 g/dl

 EPO diberikan bila Hb <9 g/dl
 Target Hb < 11,5 g/dl ( )
tidak diberikan EPO, maintenance EPO 1x/bulan
Kiat-kiat  Pada Hb 13, EPO tidak diberikan
 Pemberian EPO pada CKD V dialisis adalah SC
 EPO diberikan bila status besi (saturasi dan feritin) normal
 Target tidak lebih 2 g/dl dalam 4 minggu
 target Hb 1-2 g/dl dalam 4 minggu
  Hb 9-10 g/dl
 Tidak ada HT krisis TD ≥ 180/110
 Tidak ada gangguan koagulasi darah
 Tidak ada AMI, stroke pendarahan
 Profil Fe normal
- saturasi tranferin ≥ 25%
- Feritin ≥ 300 ng/mL

Pemberian ESA/EPO
Koreksi zat besi tidak melebihi :
 Sat transferin ≤ 30%
 Feritin ≤ 500 ng/mL

Anemia defisiensi besi absolut :

 Sat transferin < 20%
 Feritin < 100 ng/mL
  Start 20 - 50 UI/kg BB 3x seminggu. SC
atau 2x 30-75 UI/kgBB seminggu
 Darbopoietin alfa 0,45 ug/kgBB 1x seminggu
Dosis EPO SC or IV atau 0,75 ug/kgBB tiap 2 minggu
CERA SC 0,6 ug/kgBB or IV atau 1,2 ug/kgBB
tiap 4 minggu SC

 EPO δ atau EPO β dinaikkan tiap 4 minggu dair peningkatan

Peningkatan dosis 2x20 IU/kgBB per minggu (± 3000 IU/minggu)
 NB : frekuensi peningkatan dosis tidak boleh > 4 minggu
 bila dosis mencapai 11,5 g/dL, turunkan ± 25%
 
Efek samping

Hipertensi
 Stroke
 Vaskuler
 kardiovaskuler efek
 kematian
Anaemia Of CKD, Causes and Consequences
Causes of anaemia in CKD
Normal
Erythropoiesis
 Definisi

Anemia is a condition in which the number of RBCs or their oxygen-carrying

capacity is insufficient to meet physiologic needs, which vary by age, sex,
altitude, smoking, and pregnancy status (WHO).

For diagnosis and further evaluation Hb values according to NKF guidelines:

• <13.5 g/dL in adult males. (WHO-13g/dL)
• <12.0 g/dL in adult females.
 Anemia Worsens as Kidney Function Declines

100
90 Hb Levels
Prevalence of Anemia (%)

80 Hb=11-12 g/dL (n=181) 10

Hb=10-11 g/dL (n=105)
70 15
60 Hb=<10 g/dL (n=315)
15
50
8
40
17
30 62
9 8 43
20
5
10 20
14
0
<2 2.0-2.9 3.0-3.9 >4
Serum Creatinine Level (mg/dL)

Reference: Adapted from Kausz et al. Dis Manage Health Outcomes. 2002;10:505-513.
Effects of Anemia (QOL)

 QUALITY OF LIFE:

 Anemia results in poorer quality of life in patients with renal

failure.

 This correlation can be proven by the poor quality of life scores

in patients with lower Hb values.

 Many observational as well as RCT have positively

demonstrated that the QOL scores improved in patients who
were given ESA and iron to increase their Hb
Effects of Anemia
(Mor tality)

 Generation of hypoxia due to anemia is poorly tolerated in patients with

preexisting cardiac and vascular diseases. Compensatory mechanisms leads to
development of LVH.
 Observational studies do show an increase in mortality in patients
with CKD but not direct casualty.
 Interventional studies (DOPPS) show that for an increase of 1g/dL of Hb
results in 4% decline in mortality.
 Also, Medicare data show that CKD=100% and
 Effects on Anemia on
CV Health

 CV disease related mortality is 15 times more in patients with CKD.

 50% of deaths in patients with CKD are due to CV disease.

 LVH is the most common abnormality seen in patients with CKD and
there is a strong correlation between anemia and LVH.
 Tissue hypoxia due to anemia is the principal stimuli triggering the
compensatory changes that stresses the CV system
Other Effects of Anemia in CKD

 Acceleration of progression of kidney disease by oxygen deprivation.

 Increased risk of bacteremia (11% increased risk for every 1g/dl fall in Hb)

 Detrimental effects on brain and cognitive functions.

Benefits of Anemia Treatment
in CKD
 KDOQI
2006
Anemia Guidelines
 ESA in Treatment of Renal
Anemia

 rHuEPO was genetically modified proteins that were very similar to the
nascent EPO.
 Contained the 165AA backbone with one O-linked and three N-linked
gycosylated chains.
 There gycosailylated chains contain variable amounts of sialic acid
residues.
 Many forms of rHuEPO are available: Alfa, beta, omega, delta, pegylated
Comphrehensive Therapy
Monitoring Therapy
Failure of ESA Therapy
 Hemoglobin Target-
Evolving Concepts

KDOQI 2006
Anemia
Guidelines
Treat Trial
 Anemia is a significant contributor to mortality and morbidity
in CKD.

 ESA and iron supplementation forms the core of anemia

management and has to be understood in detail.

 The data on the upper limit of target Hb is conflicting but

there is a trend towards a lower value.
 Diagnosis of anaemia of CKD in adults

Treat and repeat eGFR < 60ml/min/1.73m2

Hb AND Hb ≤ 11 g/dl

Yes No

No Non renal and

haematinic Consider
deficiency excluded? other causes
Yes

No
See initial
management
Patient on algorithm
haemodialysis?
See sections
1.2 & 1.3
Yes
 Hb maintenance algorithm
(assumes ESA therapy and maintenance i.v. iron)

Measure Hb

Hb < 11 g/dl Hb 11–12 g/dl Hb 12–15 g/dl Hb > 15 g/dl

↑ ESA dose/ Consider

frequency as No change stopping i.v.
per schedule iron. ↓ ESA Stop i.v. iron.
unless Hb
unless Hb Consider
rising by dose/frequency
rising by as per schedule stopping
1g/dl/month
If Hb is 1/g/dl/month. in which case unless Hb ESA or halve
persistently low Check Hb consider falling by more dose/frequency.
see poor as per Check Hb in
ESA dose than 1g/dl/month.
response 2 weeks.
Schedule. adjustment Check Hb as
algorithm per schedule.

Ferritin < 200 µg/l?

Iron dosage schedule
Hb monitoring
Algoritma penatalaksaan anemia pada CKD 5