Patient Information Sheet:
One of the kidneys’ main jobs is to help make red blood cells. The kidneys make a hormone called erythropoietin that is a signal for the body to make red blood cells.
If your kidneys don’t work as well as they should, they make less erythropoietin, so fewer red blood cells are made. Iron levels in the body are usually low in people with advanced kidney disease.
The medical term for this condition is Anaemia of Chronic Kidney Disease. It means a low amount of red blood cells in the body caused by long-term kidney disease.
People with anaemia often feel tired and short of breath, but there can be other symptoms.
We treat anaemia with medicines, including iron tablets and iron injections. We also use ESA (also called EPO) injections and other medication (HIF-PHI) that help make erythropoietin and help make iron work better in the body.
Guideline 1: Evaluation of anaemia – Baseline investigations
People with chronic kidney disease (CKD) who develop anaemia need initial investigations in the form of blood tests to:
- Assess the severity of anaemia
- Assess the cause of anaemia: some subjects with CKD could develop anaemia due to causes other than kidney disease: such as bleeding, iron & vitamin deficiency or many other causes. It is important to perform all the required tests before concluding that the anaemia is due to CKD.
Guideline 2.1: Treatment of Anaemia with Iron therapy:
Iron is one of the building blocks of red cell formation by the body. Therefore, correction of iron deficiency is an important initial step in the treatment of anaemia of CKD.
Guideline 2.2: Treatment of Anaemia with Iron Therapy – Initiation of ESA/HIF-PHI and Iron Status:
- There are several specific blood tests arranged regularly through the kidney clinic to ensure the adequacy of iron stores in the body of subjects with CKD, and to assess how easily these iron stores are utilised by the body to correct anaemia.
- Many subjects could have their anaemia corrected by receiving iron therapy only.
- Therefore, it is important to ensure that people with CKD have adequate iron stores prior to considering the initiation of other drugs like ESA or HIF-PHI.
Guideline 2.3: Treatment of Anaemia with Iron therapy – Route of Administration
Oral iron tablets are effective in correcting iron deficiency in the majority of CKD subjects with anaemia.
Intravenous iron:
- Intravenous iron (Iron injection given by a drip into the vein, IV iron) is usually needed when iron tablets are not effective or not tolerated by subjects with CKD.
- IV iron is widely used to correct iron deficiency among people receiving haemodialysis.
- IV iron is also given routinely to people before starting on ESA of HIF-PHI therapy to make this treatment more effective.
- There are different preparations of IV iron. Some preparations are given in a small dose at frequent intervals, others are given as a large dose infused over a few hours.
- People receiving large-dose iron infusions will not require frequent treatment, unlike those receiving small-dose preparations.
- Small dose, more frequent IV iron is suitable for people receiving in-centre haemodialysis, while large dose, less frequent preparations are suitable for people with CKD not receiving dialysis or those receiving peritoneal dialysis.
Guideline 2.4: Treatment of Anaemia with Iron therapy – safety and Upper limit for iron therapy.
- Iron treatment, particularly IV iron, is not without risks, they are administered guided by the value of iron level in the blood.
- There are several tests available to assess iron levels in the blood and body.
- The commonest test is “serum Ferritin”.
- Usually, the aim of treatment with iron is to achieve a serum ferritin level between 500-700 mcg/L.
- IV iron treatment should be withheld in the presence of any active infection. It should also be avoided in people with active Hepatitis C virus infection, in some people with chronic liver disease and those with hereditary liver conditions.
- To ensure safe treatment with IV iron, people will need regular blood tests (every 1-3 months) to monitor iron levels and the response to treatment.
Guideline 3: Treatment with Erythropoiesis Stimulating Agents
- The aim of treatment of CKD with ESA preparations is to improve quality of life and reduce/avoid the need for blood transfusion.
- Like intravenous iron, ESA therapy is not without risks. The doctor will discuss the risk-benefit ratio with the receipient/their carer before initiating this treatment.
- There are different ESA preparations; some are short-acting preparations, needing to be administered more than once weekly, others are longer-acting preparations given less frequently (weekly or monthly).
- ESA preparations are given by injection: either into the vein (IV) or under the skin (subcutaneous, SC). Although SC injection allows a lower dose of the drug to produce the desired effect, the choice and route of ESA administration is determined by several factors, such as the availability of the preparation in the local hospital, the availability of access for IV administration and the choice of the recipient.
- It will be helpful if the recipient/carer discusses the need for the drug (a shared decision), available options and the risk-benefit ratio of treatment with the health care professional prior to starting therapy.
- Overcorrection of anaemia using ESA therapy could be harmful, with adverse effects on the heart and blood pressure. Therefore, treatment with ESA aims to achieve and maintain haemoglobin level between 100 and 120 g/L in adults, and slightly lower in children younger than 2 years old.
- To achieve and maintain this target Hb range, people receiving ESA therapy will need regular blood testing to assess the response to treatment and allow adjustment of ESA dose according to Hb level.
- ESA therapy is not without risks. Therefore, ESA therapy is a shared decision (balancing benefits and risks) and should be used cautiously/ avoided in people with a history of stroke, or in people with certain malignancies.
- Blood pressure needs to be monitored regularly in people receiving ESA, and if needed, blood pressure should be controlled with medications according to local guidelines.
- Very rarely, people may become immune against ESA therapy, as a result, they become severely anaemic and do not respond to any ESA drugs. People who develop this condition should stop receiving ESA therapy. They may require blood transfusions until they are treated to regain their ability to respond to ESA therapy.
Guideline 4: Treatment of Anaemia – HIF-PHI Agents
HIF-PHI are newly introduced medications that are now licensed to treat anaemia in CKD subjects. They are administered in the form of oral tablets. They act on a system in the body that is activated when the level of oxygen in the blood is low. When activated, the body produces more red blood cells. This could be partly through the production of more erythropoietin and partly through better use of available iron for blood cell production.
HIF-PHI tablets activate this system, regardless of the oxygen level in the blood. As a result, more red blood cells are produced, and anaemia is corrected.
- Like ESA, HIF-PHI treatment is dependent on the amount of iron in the body. Therefore, it is important to treat iron deficiency in any person before prescribing HIF-PHI therapy.
- Treatment with HIF-PHI should continue if and when the person is unwell for any other reason. During any illness, like surgery or chest infection, anaemia in subjects with CKD could get worse, so treatment of anaemia should continue during acute illness unless there is a reason to stop the drug.
- Overcorrection of anaemia using HIF-PHI therapy could be harmful with adverse effects on the heart and blood pressure. Therefore, treatment with HIF-PHI therapy aims to achieve and maintain haemoglobin level between 100 and 120 g/L in adults.
- To achieve and maintain this target Hb range, people receiving HIF-PHI therapy will need regular blood testing to assess the response to treatment and allow adjustment of HIF-PHI dose according to Haemoglobin level.
- HIF-PHII therapy is not without risks. Therefore, this therapy should be used cautiously/ avoided in people with a history of stroke or in people with certain malignancies.
- Blood pressure needs to be monitored regularly in people receiving HIF-PHI, and if needed, blood pressure should be controlled with medications according to local guidelines.
- HIF-PHI therapy should be avoided in people with active malignancy, those with a history of epilepsy, history of blood clots and subjects with autosomal dominant polycystic kidney disease.
Guideline 5: Blood Transfusion in people with Anaemia of CKD
- Whenever possible, people on the transplant waiting list should avoid receiving blood transfusions to avoid/ reduce the risks of rejection when they receive their transplant.
- Blood transfusion, if needed, should be decided based on each person’s requirements, rather than guided by the blood test results only.
- People with a suppressed immune system, due to a kidney transplant or due to any other medical condition, and those on the transplant waiting list should receive blood that is negative for hepatitis E virus.
Guideline 6: Peri-transplant and Post-transplant Anaemia
- Kidney transplant recipients may develop anaemia due to a variety of causes.
- It is important to investigate and identify the cause of anaemia prior to considering treatment with iron, ESA or HIF-PHI.
- If indicated, transplant recipients can be treated with iron, ESA or HIF-PHI as per the guidelines for people with CKD not on dialysis
Guideline 7: Special Populations
- Symptomatic people with CKD and cancer may be treated with iron and ESA therapy as per the guidelines for people with CKD not on dialysis.
- Pregnant subjects with CKD who develop anaemia may be treated with ESA therapy. They may be treated with IV iron from the second trimester.
- Pregnant subjects may continue ESA therapy during pregnancy.