Anemia In Chronic Renal Disease

One of your patients with chronic kidney disease stage 4 has his annual bloods done. It shows:
Hb 9.4 g/dl
Platelets 166 x 109/l
WBC 6.7 x 109/l
He is currently under the renal team and has recently been started on erythropoietin.
What will his target haemoglobin be?
A. 10-12 g/dl
B. Normal for gender
C. 9-11 g/dl
D. 9-10 g/dl
E. 11-13 g/dl

Answer:
A. 10-12 g/dl

Discussion: Anemia in CKD - aim for a Hb of 10-12 g/dl
Anemia In Chronic Renal Disease
Patients with chronic kidney disease (CKD) may develop anemia due to a variety of factors, the
most significant of which is reduced erythropoietin levels. This is usually a normochromic normocytic anemia and becomes apparent when the GFR is less than 35 ml/min (other causes of anaemia should be considered if the GFR is > 60 ml/min). Anaemia in CKD predisposes to the development of left ventricular hypertrophy - associated with a three fold increase in mortality in renal patients

Causes of anaemia in renal failure
 reduced erythropoietin levels - the most significant factor
 reduced erythropoiesis due to toxic effects of uraemia on bone marrow
 reduced absorption of iron
 anorexia/nausea due to uraemia
 reduced red cell survival (especially in haemodialysis)
 blood loss due to capillary fragility and poor platelet function
 stress ulceration leading to chronic blood loss

Management
1. The 2011 NICE guidelines suggest a target haemoglobin of 10 - 12 g/dl
2. Determination and optimization of iron status should be carried out prior to the administration of erythropoiesis-stimulating agents (ESA). Many patients, especially those on haemodialysis, will require IV iron
3. ESAs such as erythropoietin and darbepoetin should be used in those 'who are likely to benefit in terms of quality of life and physical function'