 Name: 林俊宏  gender: male  age: 40 y/o  chart number:  bed number:

chief complaint  Intermittent abdominal discomfort for days

Present illness  HTN 10+ years under Diovan and Adalat control at level of 160mmHg.  type 2 DM 10+ years under Novonorm control at unknown but stabled level  ESRD s/p CAPD since 2006/11/3.

Persent illness  2008/12/21: fever, nausea and vomiting  2008/12/24: Intermittent epigastric dull pain at P/D center.  hiccup recently  7~8 kg of body weight loss in recent one week.  severe watery diarrhea, poor appetite, bil leg edema, dysuria and mild general weakness

Present illness  Clody drainage was noted after dialysis.  Admitted to our ward on 12/24 and discharged on 12/29  admitted again on 1/6

Past history  medical history: as mention above DM, HTN, ESRD with PD  operation: sinusitis s/p 3 times  deined smoking, denied drinking, denied betel nut  denied allsegy history  occupation: 資源回收

physical examination  consciousness alert  TPR: 36.8/100/18 BP: 166/98  lung: crouse breathing sounds  heart: RHB, no murmurs  abdomen: soft and distence, normo- active bowel sounds, no tenderness, no rebounding pain, no muscle guarding  bil leg pitting edema. Gr III

Lab

A/B course 12/2412/29 1/6 cefazolin PO GM in dialylate ceftibuten PO Quinolone po cefazidine in dialytate 1/15

Impression  Peritonitis, CAPD -related.  End-stage renal disease with CAPD.  Hypertension.  Diabetes mellitus, type 2.

Anemia of chronic kidney disease: Target hemoglobin/hematocrit for patients treated with erythropoietic agents Author: Jeffrey S Berns, MD Last literature review version 16.3: 十月 2008 This topic last updated: 十月 16, 2008 Int 蔡卓倫

INTRODUCTION  Defined by WHO － Hb ＜ 13.0 g/dL for adult males and post-menopausal women － Hb ＜ 12.0 g/dL for premenopausal women  90 ％ of patients with a GFR ＜ 25 to 30 mL/min have anemia( ＜ 10 g/dL)

EPO used in US  EPO used is the standard of care for patients with anemia caused by CKD  ＞ 90 ％ of CKD patients with chronic dialysis in the US currently receive EPO, with a mean Hgb level among 12.0 g/dL ( Hariharan, S, Yang, H. Introduction. Am J Kidney Dis 2006; 47:S1 )  ＜ 35 ％ of predialysis patients with CKD in US receive EPO. ~ 65 ％ of patients have a Hgb concentration of 11 g/dL or less ( Fink, J, Blahut, S, Reddy, M, Light, P. Use of erythropoietin before the initiation of dialysis and its impact on mortality. Am J Kidney Dis 2001; 37:348. )

TARGET LEVELS  the target Hb or Hct would be defined as that value that is clinically optimal for each patient  Hgb values above 11 g/dL (Hct of 33 percent) were suggested mostly.

 Hgb levels ＞ 13 g/dL (Hct ＞ 39 ％ ) － little benefit, increased morbidity and mortality  high target Hb levels → increased the incidence of thrombotic and vascular events and death

Clinical practice guidelines  NKF-K/DOQI guideline for the anemia of CKD (2007) ： Hb 11 ~ 12 g/dL. Don ’ t ＞ 13 g/dL.  Guidelines from the Canadian Society of Nephrology (1999): Hb 11 ~ 12 g/dL  the European Renal Association/European Dialysis and Transplantation Association (ERA-EDTA) (2004) : Hb ＞ 11 g/dL, without an upper limit － patients with severe CVD and severe DM → 11~12 g/dL. － Among hemodialysis patients, don ’ t ＞ 14 g/dL  the Japanese Society for Dialysis Therapy (2004) : Hb 10 ~ 11 g/dL － 11 ~ 12 g/dL in active relatively younger patients

Normal or near-normal Hgb levels  overall mortality  cardiovascular mortality  morbidity due to cardiovascular and cerebrovascular disease  blood pressure control  quality of life and functional status  access thrombosis.

Systematic reviews  Compared to the lower Hb group, the following relative risks of adverse effects for the higher Hb groups were reported by NKF-K/DOQI Guidelines :  Mortality of patients in nondialysis CKD pt (RR 1.01, 95% CI )  Adverse cardiovascular events in nondialysis CKD pt (RR 1.24, 95% CI )  Mortality in dialysis pt (RR 1.12, 95% CI )  Adverse cardiovascular events of dialysis pt (RR 1.14, 95% CI ) NKF-K/DOQI Clinical Practice Guidelines and Clinical practice recommendations for anemia in chronic kidney disease: 2007 update of hemoglobin target. Am J Kidney Dis 2007; 50:474

Normal Hematocrit trial  whether a normal Hct value should be the target level in dialysis patients based upon improved cardiovascular morbidity and mortality  1233 H/D patients with cardiac disease (heart failure or ischemic heart disease )  Hct of 42 or 30 percent  There were no differences between two groups (incidence of myocardial infarction or stroke) ( Besarab, A, Bolton, WK, Browne, JK, et al. The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoetin. N Engl J Med 1998; 339:584.)

CHOIR and CREATE trials  The issue of whether a normal or near-normal hemoglobin value should be the target level in predialysis patients with CKD was best addressed in the CHOIR AND CREATE studies ( Drueke, TB, Locatelli, F, Clyne, N, et al. Normalization of hemoglobin level in patients with chronic kidney disease and anemia. N Engl J Med 2006; 355:2071.) ( Singh, AK, Szczech, L, Tang, KL, et al. Correction of anemia with epoetin alfa in chronic kidney disease. N Engl J Med 2006; 355:2085.)

Effect upon LVH  146 H/D patients with asymptomatic cardiomyopathy  9.5 and 10.5 g/dL or 13.0 and 14.0 g/dL  Normalization of the Hgb did not lead to a regression of LVH or LV dilatation.  However, there was a greater tendency for progressive LV dilatation in the low Hgb group compared with the normal Hgb group. (Foley, RN, Parfrey, PS, Morgan, J, et al. Effect of hemoglobin levels in hemodialysis patients with asymptomatic cardiomyopathy. Kidney Int 2000; 58:1325.)

Effect upon LVH  nearly 600 H/D patients without symptomatic cardiac disease and LVD  (9.5 to 11.5 g/dL) and (13.5 to 14.5 g/dL)  the left ventricular volume index and left ventricular mass index were similar ( Parfrey, PS, Foley, RN, Wittreich, BH, et al. Double-blind comparison of full and partial anemia correction in incident hemodialysis patients without symptomatic heart disease. J Am Soc Nephrol 2005; 16:2180)

Heart failure  an open, uncontrolled study  179 predialysis patients with heart failure  increase Hb levels from 10.5 to 13.0 g/dL  significantly improved heart function class and decreased the frequency of hospitalization ( Silverberg, DS, Wexler, D, Blum, M, et al. The effect of correction of anaemia in diabetics and non-diabetics with severe resistant congestive heart failure and chronic renal failure by subcutaneous erythropoietin and intravenous iron. Nephrol Dial Transplant 2003; 18:141. )  However, no reduction in heart failure was observed in a randomized controlled study of incident hemodialysis patients ( Parfrey, PS, Foley, RN, Wittreich, BH, et al. Double-blind comparison of full and partial anemia correction in incident hemodialysis patients without symptomatic heart disease. J Am Soc Nephrol 2005; 16:2180 )

Quality of life and functional status  In the CREATE study － Compared with those in the 10.5 to 11.5 g/dL group, patients assigned to the 13 to 15 g/dL Hgb level had better quality of life, general and mental health, physical function and role, social function, and vitality  In the CHOIR study － no quality of life benefits were observed

Other adverse effects  Motality ↑ (Normal Hematocrit trial, the CHOIR study )  An increased risk of cerebrovascular events was seen among incident hemodialysis patients randomly assigned to Hb levels of 13.5 to 14.5 g/dL versus 9.5 to 11.5 g/dL (Parfrey, PS, Foley, RN, Wittreich, BH, et al. Double- blind comparison of full and partial anemia correction in incident hemodialysis patients without symptomatic heart disease. J Am Soc Nephrol 2005; 16:2180.)  The incidence of access thrombosis was higher with normal Hgb levels in the United States Normal Hematocrit study [47,63]47,63

About blood pressure  Patients who receive EPO will develop an elevation in diastolic pressure of 10 mmHg. However, no difference in BP was observed in the two arms of the US Normal Hematocrit and CREATE studies  normal Hb levels does not confer an added risk for hypertension