Excerpt

Chronic kidney disease (CKD) is not the most common cause of anaemia in the UK, but data from different sources suggest that nationally there are around 100,000 people with the combination of CKD and a low haemoglobin level. Anaemia in this context is important because it contributes significantly to the heavy symptom burden of CKD, and because it is potentially reversible with appropriate treatment, including erythropoietin. Erythropoietin is naturally produced by the kidneys and has been available in synthetic form for the treatment of anaemia of CKD since 1989, but it remains a fairly expensive product and its usage is not straightforward. Moreover, it will not necessarily be the only therapy required for optimal treatment. Against this background, the present guideline has been commissioned to address the appropriate management of anaemia of CKD for patients in the NHS.

Contents

• Members of the Guideline Development Group
• Acknowledgements
• Preface
• Development of the Guideline
  • 1. Introduction
    • 1.1 Definition of anaemia
    • 1.2 Chronic kidney disease: definition and prevalence
    • 1.3 How to use this guideline
    • 1.4 Recommendations for children with anaemia of CKD
  • 2. Methodology
    • 2.1 Aim
    • 2.2 Scope
    • 2.3 Audience
    • 2.4 Involvement of people with anaemia of CKD
    • 2.5 Guideline limitations
    • 2.6 Other work relevant to the guideline
    • 2.7 Background
    • 2.8 The process of guideline development
    • 2.9 Disclaimer
    • 2.10 Funding
  • 3. Key messages of the guideline
    • 3.1 Key priorities for implementation
    • 3.2 Algorithms
    • 3.3 Audit criteria
• The Guideline
  • 4. Diagnostic evaluation and assessment of anaemia
    • 4.1 Diagnostic role of Hb levels
    • 4.2 Diagnostic role of glomerular filtration rate
    • 4.3 Diagnostic tests to determine iron status
    • 4.4 Measurement of erythropoietin
  • 5. Management of anaemia
    • 5.1 Initiation of ESA therapy in iron-deficient patients
    • 5.2 Maximum iron levels in patients with anaemia of CKD
    • 5.3 Clinical utility of ESA therapy in iron-replete patients
    • 5.4 Nutritional supplements
    • 5.5 Androgens
    • 5.6 Hyperparathyroidism
    • 5.7 Patient-centred care: ESAs
    • 5.8 Patient education programmes
  • 6. Assessment and optimisation of erythropoiesis
    • 6.1 Benefits of treatment with ESAs
    • 6.2 Blood transfusions
    • 6.3 Comparison of ESAs
    • 6.4 Early or deferred ESA therapy
    • 6.5 Coordinating care
    • 6.6 Providing ESAs
    • 6.7 ESAs: optimal route of administration
    • 6.8 ESAs: dose and frequency
    • 6.9 Optimal Hb levels
    • 6.10 Optimum haemoglobin levels in children with anaemia of CKD
    • 6.11 Adjusting ESA therapy
    • 6.12 Treating iron deficiency: correction
    • 6.13 Treating iron deficiency: maintenance
    • 6.14 ESAs: monitoring iron status during treatment
  • 7. Monitoring treatment of anaemia of CKD
    • 7.1 Monitoring iron status
    • 7.2 Monitoring haemoglobin levels
    • 7.3 Detecting ESA resistance
    • 7.4 Managing ESA resistance
  • 8. Research recommendations
    • Intravenous iron in children
    • Trials of ESAs in children
    • Haemoglobin levels in older people
    • ESA tolerance test
    • Iron levels in predialysis patients
    • Implementation of management algorithm
    • Other potential research topics
• Appendices
  • Appendix A Evidence-based clinical questions and literature searches
  • Appendix B Scope
  • Appendix C Health economic model: target haemoglobin in haemodialysis patients
  • Appendix D Health economic calculation: route of administration of ESAs
  • Appendix E Glossary
• References

Mission statement: The Royal College of Physicians plays a leading role in the delivery of high quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the United Kingdom and overseas with education, training and support throughout their careers. As an independent body representing over 20,000 Fellows and Members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare.

The National Collaborating Centre for Chronic Conditions: The National Collaborating Centre for Chronic Conditions (NCC-CC) is a collaborative, multi-professional centre undertaking commissions to develop clinical guidance for the NHS. The NCC-CC was established in 2001. It is an independent body, housed within the Clinical Standards Department at the Royal College of Physicians of London. The NCC-CC is funded by the National Institute for Health and Clinical Excellence (NICE) to undertake commissions for national clinical guidelines on an annual rolling programme.

Suggested citation:

National Collaborating Centre for Chronic Conditions. Anaemia management in chronic kidney disease: national clinical guideline for management in adults and children. London: Royal College of Physicians, 2006.