The most important message from the New KDIGO Anemia Guidelines is that they will move the needle in managing CKD anemia.
The guidelines are well written, balanced, and make a lot of sense. So, congratulations John McMurray and Pat Parfrey and the rest of the committee for a fantastic job.
My interpretation - think of the treatment of anemia as symptom modifying and not disease modifying. Think about the pros and cons of therapy and be particularly reluctant to begin ESA therapy in a patient with a prior history of a stroke or of cancer. Above all: individualize therapy. Basically, try to establish for your specific patient the hemoglobin trigger i.e., the hemogloblin below which an intervention will be necessary be it starting an ESA, treating with iron or administering blood.
Most importantly, the Hb threshold has been moved downwards from 10 g/dL to 9 g/dL.
I will be writing a commentary in Nature Nephrology and also participating in the KDOQI commentary of these guidelines. But trust me, I've taken out the champagne.
The key recommendations:
3.4.2 For adult CKD ND patients with Hb concentration <10.0 g/dl (<100
g/l) we suggest that the decision whether to initiate ESA therapy be
individualized based on the rate of fall of Hb concentration, prior response to
iron therapy, the risk of needing a transfusion, the risks related to ESA
therapy and the presence of symptoms attributable to anemia. (2C).
Post-script: Vacation is over!
To all my friends who've written in to ask why the sudden pause in posts, the answer is: VACATION! It was an shortened vacation (because of the Brigham Renal Board Review Course), but nevertheless a vacation at our summer beach cottage in Wiano, a small village of Osterville, Cape Cod.
The guidelines are well written, balanced, and make a lot of sense. So, congratulations John McMurray and Pat Parfrey and the rest of the committee for a fantastic job.
My interpretation - think of the treatment of anemia as symptom modifying and not disease modifying. Think about the pros and cons of therapy and be particularly reluctant to begin ESA therapy in a patient with a prior history of a stroke or of cancer. Above all: individualize therapy. Basically, try to establish for your specific patient the hemoglobin trigger i.e., the hemogloblin below which an intervention will be necessary be it starting an ESA, treating with iron or administering blood.
Most importantly, the Hb threshold has been moved downwards from 10 g/dL to 9 g/dL.
I will be writing a commentary in Nature Nephrology and also participating in the KDOQI commentary of these guidelines. But trust me, I've taken out the champagne.
The key recommendations:
3.3: We recommend using ESA therapy with great
caution, if at all, in CKD patients with active malignancy—in particular when
cure is the anticipated outcome—(1B), a history of stroke (1B), or a history of
malignancy (2C).
3.4.1 For adult CKD ND patients with Hb
concentration >10.0 g/dl (>100 g/l), we suggest that
ESA therapy not be initiated. (2D)
3.4.3: For adult CKD 5D patients, we suggest that
ESA therapy be used to avoid having the Hb concentration fall below 9.0 g/dl
(90 g/l) by starting ESA therapy when the hemoglobin is between 9.0–10.0 g/dl
(90–100 g/l). (2B)
3.4.4: Individualization of therapy is reasonable
as some patients may have improvements in quality of life at higher Hb
concentration and ESA therapy may be started above 10.0 g/dl (100 g/l). (Not
Graded)
Post-script: Vacation is over!
 |
| Dowses Beach, Wiano, Osterville |
Like painted kites, those days and nights
They went flying by
The world was new beneath the blue
Umbrella sky
(The Summer Wind, Frank Sinatra)
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