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Name: 林俊宏
gender: male
age: 40 y/o
chart number: 8282347
bed number: 3036-3
chief complaint
 Intermittent abdominal discomfort for
days
Present illness
 HTN 10+ years under Diovan and
Adalat control at level of 160mmHg.
 type 2 DM 10+ years under
Novonorm control at unknown but
stabled level
 ESRD s/p CAPD since 2006/11/3.
Persent illness
 2008/12/21: fever, nausea and vomiting
 2008/12/24: Intermittent epigastric dull
pain at P/D center.
 hiccup recently
 7~8 kg of body weight loss in recent
one week.
 severe watery diarrhea, poor appetite,
bil leg edema, dysuria and mild general
weakness
Present illness
 Clody drainage was noted after
dialysis.
 Admitted to our ward on 12/24 and
discharged on 12/29
 admitted again on 1/6
Past history
 medical history: as mention above
DM, HTN, ESRD with PD
 operation: sinusitis s/p 3 times
 deined smoking, denied drinking,
denied betel nut
 denied allsegy history
 occupation: 資源回收
physical examination
consciousness alert
TPR: 36.8/100/18 BP: 166/98
lung: crouse breathing sounds
heart: RHB, no murmurs
abdomen: soft and distence, normoactive bowel sounds, no tenderness, no
rebounding pain, no muscle guarding
 bil leg pitting edema. Gr III
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Lab
A/B course
Quinolone po
cefazidine in dialytate
ceftibuten PO
cefazolin PO
GM in dialylate
12/24
12/29
1/6
1/15
Impression
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Peritonitis , CAPD -related.
End-stage renal disease with CAPD .
Hypertension.
Diabetes mellitus , type 2.
Anemia of chronic kidney
disease: Target
hemoglobin/hematocrit for
patients treated with
erythropoietic agents
Author: Jeffrey S Berns, MD
Last literature review version 16.3: 十月 2008
This topic last updated: 十月 16, 2008
Int 蔡卓倫
INTRODUCTION
 Defined by WHO
－ Hb ＜ 13.0 g/dL for adult males
and post-menopausal women
－ Hb ＜ 12.0 g/dL for premenopausal
women
 90 ％ of patients with a GFR＜ 25 to
30 mL/min have anemia(＜10 g/dL)
EPO used in US
 EPO used is the standard of care for
patients with anemia caused by CKD
 ＞ 90 ％ of CKD patients with chronic
dialysis in the US currently receive EPO,
with a mean Hgb level among 12.0
g/dL( Hariharan, S, Yang, H. Introduction. Am J Kidney
Dis 2006; 47:S1 )
 ＜35 ％ of predialysis patients with CKD in
US receive EPO. ~ 65 ％ of patients have a
Hgb concentration of 11 g/dL or less ( Fink, J,
Blahut, S, Reddy, M, Light, P. Use of erythropoietin before
the initiation of dialysis and its impact on mortality. Am J
Kidney Dis 2001; 37:348. )
TARGET LEVELS
 the target Hb or Hct would be defined
as that value that is clinically optimal
for each patient
 Hgb values above 11 g/dL (Hct of 33
percent) were suggested mostly.
 Hgb levels ＞13 g/dL (Hct ＞ 39 ％)
－ little benefit, increased morbidity
and mortality
 high target Hb levels → increased the
incidence of thrombotic and vascular
events and death
Clinical practice guidelines
 NKF-K/DOQI guideline for the anemia of CKD (2007)：
Hb 11 ~ 12 g/dL. Don’t ＞ 13 g/dL.
 Guidelines from the Canadian Society of Nephrology
(1999):
Hb 11 ~ 12 g/dL
 the European Renal Association/European Dialysis and
Transplantation Association (ERA-EDTA) (2004) :
Hb ＞11 g/dL, without an upper limit
－ patients with severe CVD and severe DM → 11~12
g/dL.
－ Among hemodialysis patients, don’t ＞14 g/dL
 the Japanese Society for Dialysis Therapy (2004) :
Hb 10 ~ 11 g/dL
－ 11 ~ 12 g/dL in active relatively younger patients
Normal or near-normal Hgb
levels
 overall mortality
 cardiovascular mortality
 morbidity due to cardiovascular and
cerebrovascular disease
 blood pressure control
 quality of life and functional status
 access thrombosis.
Systematic reviews
 Compared to the lower Hb group, the following
relative risks of adverse effects for the higher Hb
groups were reported by NKF-K/DOQI Guidelines :
 Mortality of patients in nondialysis CKD pt (RR 1.01,
95% CI 0.63-1.61)
 Adverse cardiovascular events in nondialysis CKD pt
(RR 1.24, 95% CI 1.02-1.51)
 Mortality in dialysis pt (RR 1.12, 95% CI 0.91-1.37)
 Adverse cardiovascular events of dialysis pt (RR 1.14,
95% CI 0.79-1.64)
NKF-K/DOQI Clinical Practice Guidelines and Clinical
practice recommendations for anemia in chronic
kidney disease: 2007 update of hemoglobin target.
Am J Kidney Dis 2007; 50:474
Normal Hematocrit trial
 whether a normal Hct value should be the target level
in dialysis patients based upon improved
cardiovascular morbidity and mortality
 1233 H/D patients with cardiac disease (heart failure
or ischemic heart disease )
 Hct of 42 or 30 percent
 There were no differences between two groups
(incidence of myocardial infarction or stroke)
(Besarab, A, Bolton, WK, Browne, JK, et al. The
effects of normal as compared with low hematocrit
values in patients with cardiac disease who are
receiving hemodialysis and epoetin. N Engl J Med
1998; 339:584.)
CHOIR and CREATE trials
 The issue of whether a normal or near-normal
hemoglobin value should be the target level in
predialysis patients with CKD was best addressed in
the CHOIR AND CREATE studies
( Drueke, TB, Locatelli, F, Clyne, N, et al.
Normalization of hemoglobin level in patients with
chronic kidney disease and anemia. N Engl J Med
2006; 355:2071.)
( Singh, AK, Szczech, L, Tang, KL, et al. Correction of
anemia with epoetin alfa in chronic kidney disease. N
Engl J Med 2006; 355:2085.)
Effect upon LVH
 146 H/D patients with asymptomatic cardiomyopathy
 9.5 and 10.5 g/dL or 13.0 and 14.0 g/dL
 Normalization of the Hgb did not lead to a regression
of LVH or LV dilatation.
 However, there was a greater tendency for
progressive LV dilatation in the low Hgb group
compared with the normal Hgb group.
(Foley, RN, Parfrey, PS, Morgan, J, et al. Effect of
hemoglobin levels in hemodialysis patients with
asymptomatic cardiomyopathy. Kidney Int 2000;
58:1325.)
Effect upon LVH
 nearly 600 H/D patients without
symptomatic cardiac disease and LVD
 (9.5 to 11.5 g/dL) and (13.5 to 14.5 g/dL)
 the left ventricular volume index and left
ventricular mass index were similar
( Parfrey, PS, Foley, RN, Wittreich, BH, et
al. Double-blind comparison of full and
partial anemia correction in incident
hemodialysis patients without symptomatic
heart disease. J Am Soc Nephrol 2005;
16:2180)
Heart failure
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an open, uncontrolled study
179 predialysis patients with heart failure
increase Hb levels from 10.5 to 13.0 g/dL
significantly improved heart function class and decreased
the frequency of hospitalization
( Silverberg, DS, Wexler, D, Blum, M, et al. The effect of correction of
anaemia in diabetics and non-diabetics with severe resistant
congestive heart failure and chronic renal failure by subcutaneous
erythropoietin and intravenous iron. Nephrol Dial Transplant 2003;
18:141. )
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However, no reduction in heart failure was observed in a
randomized controlled study of incident hemodialysis
patients
( Parfrey, PS, Foley, RN, Wittreich, BH, et al. Double-blind comparison of
full and partial anemia correction in incident hemodialysis patients
without symptomatic heart disease. J Am Soc Nephrol 2005; 16:2180 )
Quality of life and functional status
 In the CREATE study
－ Compared with those in the 10.5 to 11.5
g/dL group, patients assigned to the 13 to
15 g/dL Hgb level had better quality of life,
general and mental health, physical
function and role, social function, and
vitality
 In the CHOIR study
－ no quality of life benefits were observed
Other adverse effects
 Motality↑(Normal Hematocrit trial, the CHOIR
study )
 An increased risk of cerebrovascular
events was seen among incident hemodialysis
patients randomly assigned to Hb levels of 13.5 to
14.5 g/dL versus 9.5 to 11.5 g/dL
(Parfrey, PS, Foley, RN, Wittreich, BH, et al. Doubleblind comparison of full and partial anemia correction
in incident hemodialysis patients without symptomatic
heart disease. J Am Soc Nephrol 2005; 16:2180.)
access thrombosis was
higher with normal Hgb levels in the United
 The incidence of
States Normal Hematocrit study [47,63]
About blood pressure
 Patients who receive EPO will develop
an elevation in diastolic pressure of
10 mmHg. However, no difference in
BP was observed in the two arms of
the US Normal Hematocrit and
CREATE studies
 normal Hb levels does not confer an
added risk for hypertension