Anemia In Ckd2

ANEMIA IN CKD A MAN WITH DOUBLE RECORD

Done by M.D Hani Shaban Nephrologist Department of Hammoud Hospital

Epidemiology  Worldwide 50 million people have chronic kidney disease (CKD)  CKD affects 11% of the US population  ESRD has doubled over the last 10 years to 453,000 people in the US  Management of CKD is expensive, accounting for 24% of Medicare expenditures  Adverse outcomes of CKD can be prevented or delayed by early detection and treatment

Incidence of ESRD Resulting from Primary Diseases

19% 3%

43%

12% 23% Diabetes Hypertension Glomerulonephritis Cystic Kidney Other Causes

Diabetes: Increasing prevalence worldwide

prevalence of diabetes worldwide (in million) 333

rise of prevalence of diabetes 19952025 170%

150 41%

30 developed

1985

2000

developing

2025

http://www.idf.org

Hypertension: increasing global burden Number of people (in million) with hypertension (>140/90) aged 20 years and older 154

150

120 107

100 91 76

47

52

59

75 64

57 36

2025 1.56 billion

40

Africa

Asia

Keamy Lancet 2005; 365 217

China

972 million

Middle east

Latin America

India

former USSR

Establised economy

2000

36

?Why talk about CKD

hypertension

diabetes CKD

The major risk factors for CKD are diabetes and hypertension

ST AGES OF Chroni c Ki dney Di sease (CKD) Mildly impaired

Urinary abnormalities (GFR ≥ 90 ml/min)

(GFR 60 - 89 ml/min) Moderate CKD (GFR 30 - 59 ml/min) Severe CKD (GFR 15 - 29 ml/min)

ESRD (GFR < 15 ml/min)

Stages of CKD

Prevalence Estimates of CKD in the US GFR (mL/min/1.73 (m2

Prevalence

Prevalence (%)

1

Kidney damage with normal or increased GFR

90>

5,900,000

3.3

2

Kidney damage with mild decrease in GFR

60-89

5,300,000

3.0

3

Moderate decrease in GFR

30-59

7,600,000

4.3

4

Severe decrease in GFR

15-29

400,000

0.2

5

Kidney Failure

(or dialysis) 15 <

300,000

0.2

Stage

Description

National Kidney Foundation. Am J Kidney Dis. 2002;39(suppl 1): S1-S266.

Mortality in CKD is high and increases with decreasing GFR Adjusted hazard ratio for death from any cause over 2.8years (n=1120295) 5.9

3.2 1

1.2

>60

45-59

1.8

30-44

15-29

<15

GFR ml/min/1.73sq.m

Go NEJM 2004;351;1296

Cardiovascular Mortality in CKD Adjusted hazard ratio for cardiovascular events 3.4 2.8 2 1.4 1

>60

45-59

30-44

15-29

<15

GFR ml/min/1.73sq.m Go NEJM 2004;351;1296

of Patients Start Dialysis 67% With Hct > 30% 16%

14%

15%

15%

Mean 27.9 +/- 5.4 Median 27.9

12%

12%

n = 131,484

10% 9%

8%

7%

6%

5% 3%

4%

2%

2%

38-40

40+

0% < 20

20-22

22-24

24-26

26-28

28-30

30-32

32-34

Hematocrit (%)

*131,484 patients who began dialysis between 4/1/95 and 6/30/97. Obrador, J Am Soc Nephrol 1999, 10:1793-1800.

34-36

36-38

Majority of CKD Patients Not Treated for Anemia Prior to Renal Replacement Therapy rHuEPO use

Not treated 77%

Treated 23%

Obrador et al. J Am Soc Nephrol. 1999;10:1793-1800.

N = 155,076

The Significance of Anemia in Chronic Kidney Disease

Copyright © MedReviews, LLC. McCullough PA, Lepor NE. The Deadly Triangle of Anemia, Renal Insufficiency, and Cardiovascular Disease:  Implications for Prognosis and Treatment. Rev Cardiovasc Med. 2005; 6:6. Reviews in Cardiovascular Medicine is a copyrighted publication of  MedReviews, LLC. All rights reserved.   Relationship between changes in hemoglobin (Hb) level over time and left ventricular mass index (LVMI) in a subset of 66 patients with chronic  congestive heart failure from the Randomized Etanercept North American Strategy to Study Antagonism of Cytokines Trial. *P < .0009. Adapted from  Anand I, McMurray JJ, Whitmore J, et al. Anemia and its relationship to clinical outcome in heart failure. Circulation. 2004; 110:149–154. 

Cardio-Renal-Anemia Syndrom

Anemia is a Mortality Multiplier Risk of Death Over 2 Years in Patients with Diabetes, Anemia, CKD, and Congestive Heart Failure 7.3

Relative Risk

8 6 4

2

2

1.5

4

3.7

2.9

1

2

/C

HF /C

KD /A ne m

ia

ia An em

m ia

CH F

CK D/ An e

CH F/ DM

Collins AJ. Adv Stud Med. 2003;3:S194-S197.

CK D

An em ia

es be t Di a

No ne

0

The Physiological Role of Erythropoietin

Decrease in oxygen delivery to the kidneys

Peritubular interstitial cells detect low oxygen levels in the blood Pro-erythroblasts in red bone Peritubular interstitial marrow mature cells secrete more quickly into erythropoietin (EPO) reticulocytes into the blood EPO More reticulocytes Increased oxygen delivery to tissues enter circulating blood Return to homeostasis Larger number of when response brings red blood cells oxygen delivery to (RBC) in circulation kidneys back to normal

Anemia Work-up SCr ≥ 2 mg/dL GFR < 60 ml/min

Is Hgb ≤ 12.5 g/dL ( , post-menopausal ≤ 11.0 g/dL ( , premenopausal)?

No

),

No work-up

Yes Stool Guaiac, CBC, Indices, Retic Fe, TIBC,%Sat, Ferritin

No

Iron deficiency?*

Refer for hematology /GI work-up

Yes

Normal

Treat with rHuEpo if indicated

No

Treat with Iron Anemia not corrected

Anemia (corrected; periodic follow-up)

*Laboratory values are consistent with uncomplicated iron deficiency. Adapted from National Kidney Foundation. K/DOQI Guidelines. Am J Kidney Dis. 2002;39(suppl 1):S1S266.

The

M EDUWAY

To Care For Patients

Erythropoietin levels are not useful in the diagnosis of anemia of CKD

Major Stages of Erythropoiesis Hematopoietic Stem Cell

BFU-E Bone Marrow CFU-E

Erythroblasts

Iron Dependent

Reticulocytes Circulation Erythrocytes (RBCs) (Time to maturity = 12 days) Adapted from Bron D, et al. Semin Oncol. 2001;28:1-6.

Erythropoietin Dependent

”The Problem“ ESRD

1 million

CKD 20 million

Nb of Patients 130

males 66 50.7%

females 64 49.3%

70

61.5

60 50 40 Median Age

30 20 10 0

Median Age

Etiology 35

34.8

30 25

22.7

20 15

13.2

12.4

10 6.6 5.2

5

2.2

0

DM

HTN

CGN

CPN

CAN

PCKD

1.4 FMF

UNKNOWN

ESRD USA 2003 40 35

36

30 25

24

20

19 16

15 10 5 0

5

DM

HTN

GN

Cystic Disease

Others

DM HTN GN Cystic Disease Others

Patients Undergoing Dialysis 70% 60% 50% 40%

Percentage of patients

30% 20% 10% 0% 3 sessions/week

2 sessions/week

Coverage army 7%

Others 16% Ministry 47% NSS 30%

Ministry

NSS

others

army

HBV

4%

HBV

HCV

6%

HCV

ACCORDING TO YRS % 3% 22%

11%

24% 27% 13%

<1YR

1-3YR

3-5 YR

5-10 YR

10-20 YR

>20YR

survival probability (%)

Mortality in HD 77.9 61.4

30.8 11.1

1y

2y

5y

10y

Years after starting dialysis

Survival probabilities for 1990 incident dialysis patients (from day 91) adjusted for age, gender, race and primary diagnosis USRDS 2002

survival probability (%)

Mortality in HD at HHHUMC 90

75

8m

2y Years after starting dialysis

USRDS 2002

Hg 36% 64%

>11 <11

21/08/1974

A MAN WITH DOUBLE RECORD    

Mr A.SHALHOUB 67 yr old male patient Started hemodialysis 35 yr ago HD 3 x week total 5470 session Right radiocephalic AV fistula constructed 1974

21/8/2008 12:55