update of Anemia management in chronic kidney disease What is still missing

This way What makes the standards Guidelines Own experience Economic status

STILL MISSING Iron management Aim of treatment Statistics Early Transferal

Strategies for treating renal anemia Time or GFR Prevention Dialysis Earlier start Higher target Hb (g/dl) Hb Sweet Spot

Low Hb Tiredness and exhaustion Poor quality of life High transfusion rate Higher rate of death and CV complications Death and CV Complications Hypertension Faster progression of CKD Increased Risk of Stroke Vascular access thrombosis High Hb Hb Trade Offs

March 9, 2007

The Hemoglobin Sweet Spot Hb g/dL Risk 100% 50%

March 9, 2007

Step 1 Insert the TEST CARD Step 2 Apply the SAMPLE Step 3 Read the RESULT in 2 min

STILL MISSING Iron management Aim of treatment Statistics Early Transferal

Pro-inflammatory cytokines (IL-1, TNFα, IL-6, IFNγ) EPO + + Iron Apoptosis ─ Hepcidin  Fe absorption  Fe transport  Fe availability (EPO-R, Tf, TfR, Ferriportin, DMT-1) ─ Erythropoiesis

Occult G-I losses Peptic ulceration Blood sampling Dialyser losses Concurrent meds. – e.g. aspirin Heparin on dialysis Poor appetite Poor G-I absorption Concurrent medication – e.g. omeprazole Food interactions REDUCED INTAKEINCREASED LOSSES Why are CKD patients prone to develop iron deficiency

Am J Nephrology 2007

Non – haematological benefits of iron Iron Haemoglobin Physical Performance Thermoregulation Cognitive Function Restless legs Immune function

Clinical issues in iron deficiency in CKD Assessing iron status Oral versus intravenous medication Iron management in CKD

Assessing iron status Quantification of iron stores Measurement of available iron in blood Assessment of iron uptake and utilisation by marrow

Assessing iron status Quantification of iron stores Serum ferritin, bone marrow stainable iron Serum ferritin is acute phase protein

Assessing iron status Measurement of available iron in blood Transferrin saturation = 100 X serum iron serum total iron binding capacity

Assessing iron status Assessment of iron uptake and utilisation by marrow: % hypochromic red cells, RBC zinc protophoryin

Recommended Targets for Iron Status in CKD K-DOQIEuropean Best practice Guidelines National Institute for Clinical Excellence (NICE) Serum Ferritin ceiling >100ng/ml (non- dialysis). >200ng/ml (dialysis) Not routinely>500ng/ ml >100ng/ml (target ng/ml) >100ng/ml target ng/ml Transferrin Saturation (TSAT) >20% >20% unless ferritin>800ng/ml % Hypochromic Red Cells ---<10% target <2.5% 800ng/ml CHr – reticulocyte haemoglobin >29pg/cell>29pg/cell target = 35pg/cell

Frequency of iron status tests: 1- Every month during initial ESA treatment 2- At least every 3 months during stable ESA treatment or in patients with HD-CKD not treated with an ESA © 2006 National Kidney Foundation, Inc. NKF KDOQI GUIDELINES

< 100 ng/ml ng/ml ng/ml (200 ng/ml ) ng/ml > 800 ng/ml (400 ng/ml) invalid Ferritin assessment in 10 min

Oral Iron I.V. Iron Vs

FDA reported allergic reactions to IV iron: Jan 1997-Sep 2002 Reports/million 100 mg dose equivalents Bailie et al. NDT 2005,20,

Heme – Iron polypeptide Derived from bovine haemoglobin Oral bioavailabilty 10 times greater than conventional oral iron Reduced GI side effects

Heme – Iron polypeptide

STILL MISSING Iron management Aim of treatment Statistics Early Transferal

Statistics Incidence: Measure of new patients entering ESRD/Dialysis Prevalence: Measure of patients undergoing dialysis Africa: Incidence ~ ? P.M.P ME Prevalence ~ ? P.M.P A need for more accurate data in most of the countries to plan for the future

STILL MISSING Iron management Aim of treatment Statistics Early Transferal

Transferal & Decision to treat 65% transferred when in need for urgent dialysis ( KSA) How many patients treated for their anemia in our region? How many patients reach target Hgb in our region?

More frequent monitor for Hb &iron limiting ESA when Hb over 12g/dl Optimum iron therapy lower ESA dose Conclusion A need for more accurate data related to Incidence &Prevalence Screening program for early transferral is needed

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