ANEMIA IN CKD

A MAN WITH DOUBLE RECORD

Done by M.D Hani Shaban

Nephrologist Department of
Hammoud Hospital
 Epidemiology
 Worldwide 50 million people have chronic kidney
disease (CKD)
 CKD affects 11% of the US population
 ESRD has doubled over the last 10 years to
453,000 people in the US
 Management of CKD is expensive, accounting for
24% of Medicare expenditures
 Adverse outcomes of CKD can be prevented or
delayed by early detection and treatment
Incidence of ESRD Resulting from
Primary Diseases

19%

3%
43%
12%

23%
Diabetes

Hypertension

Glomerulonephritis

Cystic Kidney

Other Causes
 Diabetes: Increasing prevalence worldwide

prevalence of diabetes worldwide (in million) rise of prevalence of diabetes 1995-

2025
333
170%

150
41%

30
developed developing

1985 2000 2025

http://www.idf.org
 Hypertension: increasing global burden
Number of people (in million) with hypertension (>140/90) aged 20 years and older

154 150

120
107
100
91
76 75
64
59 57
52
47
40
36 36
Establised

former

India

America

Middle east

China

Asia

Africa
USSR
economy

Latin

2000 2025
972 million 1.56 billion
Keamy Lancet 2005; 365 217
 ?Why talk about CKD

hypertension
diabetes

CKD

The major risk factors for CKD are diabetes and hypertension
 Urinary ST AGES OF
Chroni c Ki dney
abnormalities
(GFR ≥ 90 ml/min)

Mildly impaired
Di sease (CKD)
(GFR 60 - 89 ml/min)

Moderate CKD
(GFR 30 - 59 ml/min)

Severe CKD
(GFR 15 - 29 ml/min)

ESRD
(GFR < 15 ml/min)
Stages of CKD
 Prevalence Estimates of CKD
in the US
GFR Prevalence
Stage Description (mL/min/1.73 Prevalence
(m2
(%)
Kidney damage
1 with normal or 90> 5,900,000 3.3
increased GFR
Kidney damage
2 with mild decrease 60-89 5,300,000 3.0
in GFR
Moderate
3 30-59 7,600,000 4.3
decrease in GFR
Severe decrease
4 15-29 400,000 0.2
in GFR
5 Kidney Failure (or dialysis) 15 < 300,000 0.2

National Kidney Foundation. Am J Kidney Dis. 2002;39(suppl 1): S1-S266.

 Mortality in CKD is high and
increases with decreasing GFR
Adjusted hazard ratio for death from any cause
over 2.8years (n=1120295)
5.9

3.2
1.8
1 1.2

>60 45-59 30-44 15-29 <15

GFR ml/min/1.73sq.m

Go NEJM 2004;351;1296
Cardiovascular Mortality in CKD
Adjusted hazard ratio for cardiovascular events

3.4
2.8

2
1.4
1

>60 45-59 30-44 15-29 <15

GFR ml/min/1.73sq.m

Go NEJM 2004;351;1296
 of Patients Start Dialysis 67%
With Hct > 30%
16% 15% 15%
14% Mean 27.9 +/- 5.4
12% Median 27.9
12%
10% n = 131,484
9%
8% 7% 6%
5%

4% 3%
2% 2%

0%
< 20 20-22 22-24 24-26 26-28 28-30 30-32 32-34 34-36 36-38 38-40 40+
Hematocrit (%)

*131,484 patients who began dialysis between 4/1/95 and 6/30/97.

Obrador, J Am Soc Nephrol 1999, 10:1793-1800.
 Majority of CKD Patients Not Treated for
Anemia Prior to Renal Replacement
Therapy
rHuEPO use Not treated
77%

Treated
23%

N = 155,076
Obrador et al. J Am Soc Nephrol. 1999;10:1793-1800.
The Significance of Anemia in
Chronic Kidney Disease
Copyright © MedReviews, LLC. McCullough PA, Lepor NE. The Deadly Triangle of Anemia, Renal Insufficiency, and Cardiovascular Disease: 
Implications for Prognosis and Treatment. Rev Cardiovasc Med. 2005; 6:6. Reviews in Cardiovascular Medicine is a copyrighted publication of 
MedReviews, LLC.
All rights reserved.
 
Relationship between changes in hemoglobin (Hb) level over time and left ventricular mass index (LVMI) in a subset of 66 patients with chronic 
congestive heart failure from the Randomized Etanercept North American Strategy to Study Antagonism of Cytokines Trial. *P < .0009. Adapted from 
Anand I, McMurray JJ, Whitmore J, et al. Anemia and its relationship to clinical outcome in heart failure. Circulation. 2004; 110:149–154. 
Cardio-Renal-Anemia Syndrom
 Anemia is a Mortality Multiplier
Risk of Death Over 2 Years in Patients with Diabetes, Anemia,
CKD, and Congestive Heart Failure
7.3
8
6 4
Relative Risk

3.7
2.9
4 2 2
1.5
1
2
0
D

F
ia

ia
ne

ia
es

ia
CH
CK
em

em

m
No

t
be

ne
An

An
An
a

/A
Di

F/
D/

KD
CH
CK

/C
HF
/C
Collins AJ. Adv Stud Med. 2003;3:S194-S197.
DM
 The Physiological Role of
Erythropoietin
Decrease in oxygen
delivery to the kidneys
Peritubular interstitial cells detect
low oxygen levels in the blood Pro-erythroblasts
in red bone
Peritubular interstitial marrow mature
cells secrete more quickly into
erythropoietin (EPO) reticulocytes
into the blood
EPO More
reticulocytes
Increased oxygen
delivery to tissues enter
circulating
blood
Return to homeostasis Larger number of
when response brings red blood cells
oxygen delivery to (RBC) in circulation
kidneys back to normal
 Anemia Work-up
SCr ≥ 2 mg/dL
GFR < 60 ml/min

Is Hgb ≤ 12.5 g/dL No

( , post-menopausal ),
No work-up
≤ 11.0 g/dL ( ,
premenopausal)?

Yes

Stool Guaiac, No Iron No Refer for

CBC, Indices, Retic deficiency?* hematology
Fe, TIBC,%Sat, Ferritin /GI work-up
Yes
Normal
Treat with rHuEpo if indicated Treat with Iron

Anemia not Anemia (corrected;

corrected periodic follow-up)
*Laboratory values are consistent with uncomplicated iron deficiency.
Adapted from National Kidney Foundation. K/DOQI Guidelines. Am J Kidney Dis. 2002;39(suppl 1):S1-
S266.
The
M EDUWAY
To Care For Patients

Erythropoietin levels are not

useful in the diagnosis of
anemia of CKD
 Major Stages of
Erythropoiesis
Hematopoietic Stem Cell

BFU-E
Bone
Marrow
Erythropoietin
CFU-E
Dependent

Erythroblasts
Iron
Dependent

Reticulocytes

Circulation
Erythrocytes (RBCs)
(Time to maturity = 12 days)

Adapted from Bron D, et al. Semin Oncol. 2001;28:1-6.

”The Problem“

ESRD 1 million

CKD
20 million
 Nb of Patients
130

males 66 females 64
50.7% 49.3%
70 61.5
60
50
40
Median Age
30
20
10
0
Median Age
 Etiology
35 34.8

30

25
22.7

20

15 13.2
12.4

10
6.6
5.2
5
2.2
1.4

0 DM HTN CGN CPN CAN PCKD FMF UNKNOWN

 ESRD USA 2003
40
36
35
30
25 24 DM
HTN
20 19
16 GN
15
Cystic Disease
10 Others
5 5

0
DM HTN GN Cystic Others
Disease
Patients Undergoing Dialysis

70%
60%

50%
40%
Percentage of
30% patients
20%

10%
0%
3 sessions/week 2 sessions/week
 Coverage

army
7%
Others
16%
Ministry NSS
Ministry
47% others army

NSS
30%
HBV

4%

HBV
HCV

6%

HCV
ACCORDING
3%
TO YRS %
11% 22%

24%
27%
<1YR 1-3YR
13%
3-5 YR 5-10 YR

10-20 YR >20YR
 Mortality in HD

77.9
survival probability (%)

61.4

30.8

11.1

1y 2y 5y 10y
Years after starting dialysis

Survival probabilities for 1990 incident dialysis patients (from day 91)
adjusted for age, gender, race and primary diagnosis
USRDS 2002
Mortality in HD at HHHUMC
survival probability (%)

90

75

8m 2y
Years after starting dialysis

USRDS 2002
 Hg

36%

64%

>11
<11
21/08/1974
 A MAN WITH DOUBLE RECORD
 Mr A.SHALHOUB 67 yr old male patient
 Started hemodialysis 35 yr ago
 HD 3 x week total 5470 session
 Right radiocephalic AV fistula constructed
1974
21/8/2008
12:55