Download the Lothian shared care protocol for GP/hospital prescribing
All patients with chronic anaemia associated with chronic kidney diesease (CKD) should be investigated for possible treatment, irrespective of the stage of kidney disease and the requirement for renal replacement therapy.
Anemia should be investigated in pateints with CKD when Hb falls below:
- <11.5 g/dl in adult female patients
- <13.5g/dl in adult male patients
- <12.0g/dl in adult male patients > 70 years
The British Renal Association, in their 2002 standards document stated that dialysis patients with chronic renal failure (CRF) should achieve a haemolglobin of 10g/dl within six months of being seen by a nephrologists, unless there is a specific reason. To achieve this target it is necessary to aim for a Hb of 11-12.5 g/dl with a range of 10-14g/dl.
Epo for hospital-based patients is currently prescribed from the hospital pharmacy. Community based patients (CAPD, Pre-dialysis, failing transplant and PD) can receive EPO from the hospital and their GP via a shared care agreeement - willingness of the GP to proceed should be confirmed for patients on PD or pre-end stage.
First prescription of EPO is a decision for senior staff. It should only be considered in PD patients after an initial stabilisation period on dialysis of three months, as there is often a spontaneous rise in Hb.
Assessing iron status
Is difficult and there is not a single fool-proof method. Ferritin <50ug/l unequivocally proves iron deficiency, and <100ug/l is very likely to do so. As ferritin is an acute phase protein, levels may sometimes be higher even in the presence of functional iron deficiency, and a level of <300ug/l (or Transferrin sat [Tsat] <20%) should probably lead to IV iron therapy if there is an inadequate response to usual doses of EPO. Expect most patients to run along at at least 100ug/l.
There is evidence to suggest that if ferritin levels are within normal limits (50-70 ug/l), or if the patient is on haemodialysis, the rate of absorption of oral iron supplementation is not sufficient to supply the need of iron for Hb production.
Transferrin saturation (TSAT) is a measure of the ability to mobilise stored iron for red cell production. It can be calculated by
TSAT (%) = (serum Fe / Total Iron Binding Capacity [TIBC]) x 100
If TSAT < 20% this is indicative of functional iron deficiency even if the ferritin levels are adequate. This may respond to treatment with IV iron.
|The full local protocol runs to 11 pages: this is a concise version. Download the full protocol (pdf file, 188kb)|
|1. Indication:||Hb consistently below 11 g/dl1|
|2. Contra-indication:||Uncontrolled hypertension|
|3. Before starting, check:||
|4. Starting dose:||Haemodialysis:
Peritoneal or pre-dialysis:
|5. Target Hb:||
The intervals (in weeks) between checking Hb & iron studies are:
*until stability confirmed
|7. Blood pressure:||BP is checked every time epoetin is administered.|
8. Dose adjustment:3
Induction period ( Hb <11 g/dl )
Stable period (Hb >10 g/dl)
* consider period of discontinuation
|9. Stopping EPO:||If EPO is stopped because of a sharp rise in Hb it must be recommenced at a lower dose 2 weeks after discontinuation.|
|10. EPO Resistance||
EPO doses ≥250units/kg/week4 should be disucussed with senior staff; patients should be investigated for causes of EPO resistance. This shoud include a retic count.
- Recmmoended Starting Hb in European Best Practice Guidlines (EBPGs) quoting evidence of level A.
- Caution is advised in taking Hb above 12/g/dl in patients with diabetes, particularly those with peripheral vascular disease; evidence level C.
- Modified from EBPGs, evidence level C.
- Definition of EPO resistance in EPGs is 300 units/kg/week
Patients on Epo therapy, and patients on haemodialysis, will almost always require a higher degree of iron replacement than can be delivered by oral supplementation in order to maintain the haemoglobin levels that are recommended. Some pre-dialysis, transplant and peritoneal dialysis patients will not need that level of iron replacement therapy, and oral iron supplements will be sufficient for them. Some patients may not need any iron supplements at all. Oral iron should be discontinued when patient is receiving IV iron. We use iron saccharate (Venofer™) when intravenous iron is required. IV iron therapy should be ongoing, rather than intermittent treatments, when a need has been identified.
Patients who have never had Venofer™ before must be given a supervised test dose before commencing a course of treatment. Give 20mgs over 1-2mins (more conveniently as part of infusion). Wait 15 mins. Proceed with remainder of dose thereafter.
Note that it is sensible to give at least a single dose to all patients who are to move to satellite unit dialysis, so that treatments can be continued there if necessary, without the need to return to the centre for a test dose.
Severe allergic reactions are rare but when they occur are usually anaphylactoid. Discontinue infusion, give 0.5ml 1:1000 adrenaline i.m. and oxygen as initial treatment if this occurs followed with cholorphenamine and hydrocortisone as required.
Patients on haemodialysis can receive IV iron whilst on dialysis, at any time during the procedure. Those requiring iron who are non dialysis patients can receive 200 mgs (Venofer™) in the ward or clinic as a slow bolus IV injection (20mgs (1ml) per minute, or diluted with 100mls N saline and given over 30 minutes on the basis of their last iron studies). Blood should be taken for repeat iron studies before it is given.
The full protocol for the administration of Venofer™ should be referred to.
Transfusions should be avoided as far as possible in patients who are on (or who in the future may be on) the transplant list.
All blood which is given to patients with renal disease, who may be transplant candidates, should be treated to remove white blood cells. The Blood Transfusion Service now routinely provides leucocyte-depleted producs, thanks to BSE and nvCJD. The white cell content of each unit will be less than 5 x 106.
- Lothian Joint Formulary shared care protocols for prescribing in primary care include several epoetins. LJF home page
- About renal anaemia (edren textbook)
Acknowledgements: John Webster and Sue Mann were the original authors for this page, revised by Paddy Gibson and Wendy King. The date it was last modified is shown in the footer.