Guidelines of Erythropoietin Therapy in Chronic Kidney Disease
Patients
A. when to initiate anemia work-up in chronic kidney disease (CKD)
patients:
1. Hgb < 11 g/dl , Hct <33% in pre-menopausal females and pre-pubertal
patients
2. Hgb < 12 g/dl, Hct < 37% in adult males and post-menopausal females
B. The following work-up should be performed before Erythropoietin (Epoetin)
therapy is begun:
1.
2.
3.
4.
Hgb and/or Hct
RBC indices
Reticulocyte count
Iron parameters:
- serum iron (50-160mcg/dl)
- total iron binding capacity (TIBC) (250-400mcg/dl)
- percent transferring saturation (TSAT) (20-40%)
- Serum ferritin (F=12-150ng/ml, M=15-200ng/ml)
5. A test for occult blood in stool
C. Correct any iron deficiency anemia if present with iron supplement.
D. If no cause for anemia other than chronic kidney disease is detected, based on
the previous work-up, and serum creatinine is ≥ 2 mg/dl, anemia is most likely
due to Erythropoietin deficiency.
- See figure number 1-
E. Administration of Epoetin
1. Epoetin should be given subcutaneously (SC) in CKD and peritoneal
dialysis patients.
2. The most effective route of Epoetin administration is SC in
hemodialysis patients
3. When Epoetin is given SC, the site of injection should be rotated with
each administration.
4. The SC adult dose should be 80-120 units/kg/wk in 2-3 divided doses.
5. Pediatric patients < 5 years old frequently require higher doses ( 300
units/kg/wk) than older pediatric patients and adults.
6. If the initial administration of Epoetin is IV for hemodialysis patients,
the dose should be 120-180 units/kg/wk given in three divided doses
(50% higher than the SC dose).
7. For hemodialysis patients who are being switched from IV to SC
administration of Epoetin but have not yet achieved the target
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Hgb/Hct, the total weekly IV dose should be administered SC in two to
three divided doses. For those achieving the target Hgb/Hct, the initial
weekly SC dose should be two-thirds the weekly IV dose.
F. Monitoring and titration of Epoetin therapy
1. Hgb/Hct should be measured every 1-2 weeks following initiation of
treatment or following a dose increase or decrease, until a stable target
Hgb/Hct and Epoetin dose have been achieved.
2. Once a stable target Hgb/Hct and Epoetin dose have been achieved,
Hgb/Hct should be monitored every 2-4 weeks.
3. The target range for hemoglobin and hematocrit should be 11-12 g/dl
and 33%-36%, respectively.
4. The target range for TSAT and serum ferritin should be ≥20% and
≥100ng/ml, respectively.
5. If Hct level increased by < 2 percentage points over a 2-4-week period,
increase the Epoetin dose by 50%.
6.
If Hct level increased by 8% per month, or if exceeds the target level
reduce the dose of Epoetin by 25%.
7. For peritoneal dialysis patients in whom SC or IV administration of
Epoetin is not feasible, intraperitoneal (IP) administration may be
considered. IP administration must be done into a dry abdomen or one
with a minimal amount of dialysate.
8. Blood pressure should be monitored in all patients with CKD,
particularly during initiation of Epoetin therapy.
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Serum
creatinine ≥
2mg/dl?
Yes
Check Hgb
No
≤12.5 (♂, postmenopausal ♀)
≤ 11
(♀/prepubertal)?
No work-up
Yes
Work-up
CBC, indices, Retics,
iron,TIBC,Fe,TSAT,Ferritin
, stool guaiac
Refer for hematology
work-up
No
Normal?
No
Yes
No
Treat with Epoetin if
indicated
Treat with iron
Anemia not
corrected
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Fe
deficiency?
Anemia
corrected;
periodic
follow-up
Figure 1. Anemia workup for CKD patients
Iron Support Guidlines
Iron supplementation usually is essential to assure an adequate response to Epoetin in
patients with CKD because the demands for iron by the erythroid marrow frequently
exceed the amount of iron that is immediately available for erythropoiesis ( as
measured by percent transferrin saturation) as well as iron stores ( as measured by
serum ferritin.
These guidelines suggest that the regular use of small doses of intravenous iron (IV),
particularly in the hemodialysis patients, will prevent iron deficiency and promote
better erythropoiesis than can oral iron therapy.
1. To achieve and maintain an Hgb 11 to 12 g/dl ( Hct of 33% to 36%), most
hemodialysis patients will require intravenous iron on a regular basis.
2. The adult CKD, home hemodialysis, and peritoneal dialysis patient may need
500 to 1000 mg of iron dextran administered IV in a single infusion, and
repeated as needed.
3. The Anemia Work Group recommends for administering IV iron dextran or
iron gluconate in adult hemodialysis patients with absolute iron deficiency (
TSAT is < 20% and/or the serum ferritin is < 100 ng/ml) is 100 mg of iron
dextran or 125 mg of iron gluconate during each dialysis for 10 or 8 doses
respectively.
4. For maintenance iron therapy, treatment, and prevention of functional iron
deficiency ( once the patient’s TSAT is ≥20% and the serum ferritin is ≥100
ng/ml), the recommendation is 25 to 100 mg of intravenous dextran every
week for 10 weeks, or 31.25 to 125 mg of iron gluconate every week for 8
weeks, with measurement of TSAT and serum ferritin no sooner than 2 to 7
days after the last dose, depending on the magnitude of the above doses. Doses
of 100 to 125 mg require 7 days to elapse for accurate monitoring.
Measurement of TSAT and serum ferritin may be inaccurate if they are
performed within 14 days of receiving a single dose of 1 gram or more of iron
intravenously.
5. In patients in whom TSAT is ≥50% and/or serum ferritin is ≥800ng/ml, IV
iron should be withheld for up to 3 months, at which time the iron parameters
should be re-measured before IV iron is resumed. When TSAT and serum
ferritin have fallen to ≤50% and ≤800ng/ml, IV iron can be resumed weekly at
a dose reduced by one third to one half.
Monitoring Iron Status
1. During the initiation of Epoetin therapy and while increasing the Epoetin dose
in order to achieve an increase in Hgb/Hct, The TSAT and the serum ferritin
should be checked every month in patients not receiving IV iron, and at least
once every 3 months in patients receiving IV iron, until target Hgb/Hct is
reached.
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2. Following attainment of the target Hgb/Hct, TSAT and serum ferritin should
be determined at least once every 3 months.
Reference:
National Kidney Foundation. K/DOQI. Clinical practice guidelines for anemia of
chronic kidney disease. Am J Kidney Dis 2001;37:s182-s238.
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