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

2. This way What makes the standards Guidelines Own experience Economic status

3. STILL MISSING Iron management Aim of treatment Statistics Early Transferal

4. Strategies for treating renal anemia 15 10 5 Time or GFR Prevention Dialysis Earlier start Higher target 1990 1994 1998 2002 Hb (g/dl) Hb Sweet Spot

5. 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

6. March 9, 2007

8. The Hemoglobin Sweet Spot 1112139 Hb g/dL Risk 100% 50%

9. March 9, 2007

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

11. STILL MISSING Iron management Aim of treatment Statistics Early Transferal

12. 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

13. 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

14. Am J Nephrology 2007

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

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

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

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

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

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

21. 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 200-500ng/ml) >100ng/ml target 200-500 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

22. 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

23. < 100 ng/ml100 -174 ng/ml175 - 225 ng/ml (200 ng/ml ) 226 - 800 ng/ml > 800 ng/ml (400 ng/ml) invalid Ferritin assessment in 10 min

24. Oral Iron I.V. Iron Vs

25. FDA reported allergic reactions to IV iron: Jan 1997-Sep 2002 Reports/million 100 mg dose equivalents Bailie et al. NDT 2005,20,1443-1449

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

27. Heme – Iron polypeptide

28. STILL MISSING Iron management Aim of treatment Statistics Early Transferal

29. 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

30. STILL MISSING Iron management Aim of treatment Statistics Early Transferal

31. 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?

32. 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

33. Thank you and any questions ???