The KDIGO anemia guideline in practice: case scenarios

I don’t agree with everything recommended in the KDIGOanemia guideline but it is on the whole a much more sensible and balanced approach toward  the treatment of anemia than the 2006 KDOQI guideline of 2006 and it’s  update in 2007.  Here I present 3 common case scenarios interpreted through the KDIGO anemia lens.

Case Scenarios

1. A 70-year old man having his first initiation on chronic hemodialysis. He feels well, although he does feel tired in the evening. He has a prior history of a stroke 4 years previously, and was treated for prostate cancer 6 years previously. His Hb has been stable at 9.2 g/dL and he is iron replete (Tsat 24%, ferritin 128 ng/ml). He is currently not being treated with an ESA. The dialysis unit protocol recommends that you start him on 5000 units of epogen q dialysis. What should you do?

The KDIGO anemia guideline recommends that great caution should be exercised in treating patient’s with a past history of stroke. In the TREAT study patient’s treated with darbepoetin had a 2-fold increased in stroke (5% versus 2.6%), whereas if the patient had a prior risk of stroke and is treated with dabepoetin the risk goes up to 12% compared to 4% if treated with placebo

What should you do as a dialysis doctor? First, ask the patient about a prior history of stroke or cancer and make sure you are very cautious with using ESA. And, second, if the patient is doing well hold off on starting an ESA. What should you do as a dialysis unit medical director? The correct answer would be to design a questionnaire that is completed prior to each patient being initiated on ESA. Two questions should be there: any history of a stroke? Any history of cancer?  Your dialysis unit may not abandon the use of an anemia protocol but the anemia protocol is now outdated and the focus should be individualizing anemia management.

2. An 59-year old patient on dialysis has a Hb concentration that, over a 3-month period, ranges from 9.8 to 11.3 g/dL. The patient complains of fatigue whenever her Hb concentration falls below 11 g/dL. She is iron replete. What should you do?

The FDA has determined that “If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of ESA.” However, the FDA emphasizes the importance of individualizing ESA therapy, and no Hb level has been demonstrated to be free of risk. The KDIGO anemia guideline recommends that the Hb level should not exceed 11.5 g/dL. Therefore, the approach in this patient should be to counsel her on the risk of ESA therapy, andto manage her at a Hb concentration that allows her to be functional. Maximizing her quality of life with ESA therapy is reasonable, as long as she understands the risks and reward of this strategy. 

3. A 62-year old woman on chronic hemodialysis using a long-standing tunneled line in the right internal jugular vein has an average Hb concentration in the 9.6 to 10.1 g/dL range on 15,000 units of Epogen each week. What should you do?

This patient has stable ESA hypo-responsiveness. The KDIGO anemia panel defines a patient as having ESA hypo-responsiveness “if they have no increase in Hb concentration from baseline after the first month of ESA treatment on appropriate weight-based dosing (guideline 3.13.1: not graded)". And, KDIGO recommends that the approach toward managing ESA hypo responsiveness should be “For patients who remain hypo responsive despite correcting treatable causes, we suggest individualization of therapy, accounting for relative risks and benefits of (guideline 3.14.1: level 2D recommendation)”, and “in patients with acquired ESA hypo responsiveness, we suggest avoiding repeated escalations in ESA dose beyond double the dose at which they had been stable. (guideline 3.14.2: level 2D recommendation)". It would optimal to treat the patient with a lower ESA dose. Confirming an inflammatory mileau would be reasonable – an elevated ferritin and an elevated CRP would be compatible. The likeliest cause of ESA hyporesponsiveness aside from the obvious possibility of iron deficiency is an indolent infection in the tunneled line. It would be worth doing blood cultures from the tunneled line and even considering a guidewire change of the tunneled dialysis catheter. Looking for other causes of inflammation, such as a sacral sore or a foot ulcer would be important also.