Global Nephrology: Anemia Management in the UK: Much Ado About Nothing or Plenty of Room for Improvement

The publication of the 2010 UK Renal Registry (UKRR) data published in Nephron Clinical Practice on anemia provides tremendous food for thought in light of the recently published KDIGO anemia guidelines and the UK NICE Anemia guidelines.

Some key findings about anemia in hemodialysis patients

53.6% of patients commenced dialysis therapy with Hb less than 10.0 g/dl (median Hb 10.1 g/dl).

• The median Hb of haemodialysis (HD) patients was 11.5 g/dl with an inter- quartile range (IQR) of 10.5–12.3g/dl.
• Of prevalent HD patients, 52.7% had Hb >10 and <12 g/dl. 84.6% had Hb >10.0 g/dl.
• Erythropoietin Stimulating Agent (ESA) dose was higher for HD than PD patients (9,020 vs. 6,202 IU/week).

How does this relate to the UK NICE guidelines and KDIGO?

UK NICE Anemia Guidelines: (I also discuss these guidelines in an earlier post).

• “The correction to normal levels of Hb with ESAs is not usually recommended in people with anaemia of CKD.

• Typically maintain the aspirational Hb range between 10 and 12 g/dl for adults, young people and children aged 2 years and older, and between 9.5 and 11.5 g/dl for children younger than 2 years of age, reflecting the lower normal range in that age group.”

KDIGO Anemia Guidelines (I also discuss these guidelines elsewhere) 

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)

3.5.1: In general, we suggest that ESAs not be used to maintain Hb concentration above 11.5 g/dl (115 g/l) in adult patients with CKD. (2C)

Conclusion – only approximately one-half of the UK dialysis patients are within the “NICE” or KDIGO recommended ranges. Even fewer are likely to be in the optimal Hb range of 9 to 11.5 g/dL. And, without doubt even fewer in the recommended FDA ESA label suggested range of 10 to 11 g/dL. Indeed, since most UK dialysis patients have a Hb >10 g/dL, it is likely that a substantial proportion of patients have Hb levels >12 g/dL. The answer to the question - "much ado about nothing?" is "NO" - plenty of room for improvement.