P157
MANAGEMENT OF SIGNIFICANT ANAEMIA WITH ESA IN PREGNANT
WOMEN WITH CHRONIC KIDNEY DISEASE
Morad, S1, Mahmud, A1, Kirby, H2, Knox, E1, Day, C2, Lipkin, G2
1
Maternal Medicine, Birmingham Women’s Hospital, 2Renal Medicine, Queen Elizabeth
Hospital Birmingham
BACKGROUND: Women with chronic kidney disease are at high risk for the development
of significant anaemia. This is often poorly responsive to oral iron and associated with
marked symptoms. In addition there is often a short period of time in which to optimize
haemoglobin levels prior to delivery. Evidence-based guidance on the treatment of such
anaemia in these patients is lacking, although Erythropoeisis-Stimulating Agents (ESA) are
frequently used despite concerns about the potential risks of hypertension and venous
thromboembolism.
DESIGN: Retrospective study of pregnant women referred to the renal anaemia clinic from
the combined renal-obstetrics clinic.
FINDINGS: 26 women having 29 pregnancies with chronic kidney disease were referred to
the renal anaemia clinic from 1996 to 2011. The aetiology of their renal disease was as
follows:
Transplant status
Renal Disease
Reflux nephropathy (4)
Focal segmental glomerulosclerosis (1)
Native kidneys:
Lupus nephritis (4)
Adult polycystic kidney disease (1)
(22 women)
Unknown aetiology (4)
Renal TB (1)
IgA nephropathy (3)
Secondary to liver failure (1)
Diabetic nephropathy (2)
Ureteric obstruction (1)
Reflux nephropathy (1)
Kidney transplant: Medullary cystic disease (1)
Alport’s Syndrome (1)
Focal segmental glomerulosclerosis (1)
(4 women)
Two had intravenous iron alone, the rest had both intravenous iron and ESA. Iron was given
as per our pre-dialysis protocol and ESA titrated to aim for a Hb of 10 g/dl. We have used
erythropoietin alpha, beta, darbopoietin and Micera. Intravenous iron preparations include
iron glucose and more recently iron carboxymaltose. In addition four women required blood
transfusions: two were transfused due to symptomatic anaemia (Hb 6.8 and 5.9 in early
pregnancy), one was transfused due to antepartum haemorrhage in threatened preterm labour,
and one due to postpartum haemorrhage
Hb (g/dL) at which Number of patients Creatinine (μmol/L) at
Number of patients
ESA commenced
which ESA commenced
5.0-5.9
1
<100
1(1Tx)
6.0-6.9
2
100-124
6(2Tx)
7.0-7.9
6
125-149
2(2Tx)
8.0-8.9
9
150-174
1
9.0-9.9
4
175-199
2
≥ 10.0
1
200-299
3
300-399
1
≥400
3
CONCLUSION: We have found ESA and intravenous iron useful tools in the treatment of
symptomatic anaemia in pregnant patients with chronic kidney disease. There is some
evidence that transplant patients require ESA at a higher level of renal function than those
with native renal disease.