Renal Anaemia - Effective Management

Current issues in anaemia management

Importance of effective management

Renal anaemia further increases the risk of cardiovascular disease¹, is already more prevalent in patients with chronic kidney disease (CKD) than in the general population² and is the major cause of death in CKD³.
Renal anaemia has a substantial negative impact on quality of life, impairing general health and cognitive and immune function.

Achieving treatment targets

In view of the problems associated with renal anaemia and the increasing prevalence and high morbidity and mortality of CKD, effective management is critical in alleviating the burden of renal anaemia and CKD.

Early identification

Although the management of renal anaemia is improving and the annual proportion of patients with CKD not on dialysis is increasing, CKD and anaemia are often diagnosed and managed late in the course of the disease. At initiation of dialysis, many patients with CKD still have Hb levels significantly below the currently recommended level at which therapy should be initiated¹⁵. Early diagnosis and early initiation of treatment is particularly important for effective anaemia management because it has been shown to help prevent further progression of cardiovascular disease, reduce hospitalisations and treatment costs, and decrease mortality^3,4,6,7.

Patient distribution

*The data reported here have been supplied by the United States Renal Data System (USRDS). The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the U.S. government.⁸

Challenges in anaemia management table

Haemoglobin variability

Challenges in effective management also include variations in the erythropoietic activity. Current treatments can cause intermittent fluctuations in erythropoietic activity, resulting in fluctuations of Hb concentration^9,10. These episodes of ‘haemoglobin fluctuation’ can happen for a number of reasons including: changes in drug dose, biological response and pharmacokinetic variation of the patient, inflammatory or infectious disease processes, or haemodialysis adequacy. These variations in haemoglobin typically occur up to 3 times per year and result in patients spending periods of time above or below the Hb target range¹¹. This may cause damage to tissues and organs containing cells with erythropoietin receptors such as brain tissue, blood vessels, retinas, intestines and kidneys¹². To avoid fluctuations frequent dosing adjustments (on average 6 per year) may be required to keep Hb levels within the desired target range¹².

References:
1. Weiner DE, Tighiouart H, Vlagopoulos PT, et al. Effects of anaemia and left ventricular hypertrophy on cardiovascular disease in patients with chronic kidney disease. J Am Soc Nephrol 2005;16:1803–10.
2. Silverberg D. Outcomes of anaemia management in renal insufficiency and cardiac disease. Nephrol Dial Transplant. 2003;18:ii7–
3. Parfrey P. Anaemia in chronic renal disease: lessons learned since Seville 1994. Nephrol Dial Transplant 2001;16:41–5.
4. Obrador GT, Roberts T, St. Peter WL, et al. Trends in anaemia at initiation of dialysis in the United States.Kidney Int 2001;60:1875–84.
5. Gouva C, Nikolopoulos P, Ioannidis JP, et al. Treating anaemia early in renal failure patients slows the decline of renal function: a randomized controlled trial.Kidney Intl 2004;66:753–60.
6. Lu WX, Jones-Burton C, Zhan M, et al. Survival benefit of recombinant human erythropoietin administration prior to onset of end-stage renal disease : variations across surrogates for quality of care and time. Nephron Clin Pract 2005;101:c79–c86.
7. Portolés J. The beneficial effects of intervention in early renal disease. Nephrol Dial Transplant 2001;16:12–5.
8. US Renal Data System, USRDS 2006 Annual Data Report: atlas of end-stage renal disease in the United States, National Institutes of Health, National Institutes of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2006.
9. Berns JS, Elzein H, Lynn RI, et al. Haemoglobin variability in epoetin-treated hemodialysis patients. Kidney Int 2003;64:1514–21.
10. Breiterman-White R. Haemoglobin variability: impact on anaemia management practices. Nephrol Nursing J 2003;30:456–9.
11. Collins AJ, Brenner RM, Ofman JJ, et al. Epoetin alfa use in patients with ESRD: an analysis of recent US prescribing patterns and haemoglobin outcomes. Am J Kidney Dis 2005;46:481–8.
12. Fishbane S, Berns JS. Haemoglobin cycling in hemodialysis patients treated with recombinant human erythropoietin. Kidney Int 2005;68:1337–43.