Anaemia management in people with chronic kidney disease

National Institute for Health and Clinical Excellence

Key priorities for implementation

When to begin treating the anaemia

• Consider investigating and managing anaemia in people with CKD if:
  • their Hb level falls to 11 g/dl or less (or 10.5 g/dl or less if younger than 2 years) or
  • they develop symptoms attributable to anaemia (such as tiredness, shortness of breath, lethargy and palpitations

Who should receive ESAs

• Treatment with erythropoiesis-stimulating agents (ESAs) should be offered to people with anaemia of CKD who are likely to benefit in terms of quality of life and physical function

Agreeing a plan for ESA treatment

• ESA treatment should be clinically effective, consistent and safe in people with anaemia of CKD. To achieve this, the prescriber and patient should agree a plan that is patient-centred and includes:
  • continuity of drug supply
  • flexibility of where the drug is delivered and administered
  • the lifestyle and preferences of the patient
  • cost of drug supply
  • desire for self-care where appropriate
  • regular review of the plan in light of changing needs

Aspirational range and action thresholds for Hb

• When determining individual aspirational Hb ranges for people with anaemia of CKD, take into account:
  • patient preferences
  • symptoms and comorbidities
  • the required treatment
• The correction to normal levels of Hb with ESAs is not usually recommended in people with anaemia of CKD:
  • Typically maintain the aspirational Hb range between 10 and 12 g/dl for adults, young people and children aged 2 years and older, and between 9.5 and 11.5 g/dl for children younger than 2 years of age, reflecting the lower normal range in that age group
  • To keep the Hb level within the aspirational range, do not wait until Hb levels are outside the aspirational range before adjusting treatment (for example, take action when Hb levels are within 0.5 g/dl of the range's limits

Age

• Age alone should not be a determinant for treatment of anaemia of CKD

Iron supplementation: aspirational ranges

• People receiving ESA maintenance therapy should be given iron supplements to keep their:
  • serum ferritin levels between 200 and 500 µg/l in both haemodialysis and non-haemodialysis patients, and either
    • transferrin saturation level above 20% (unless ferritin is greater than 800 µg/l) or
    • percentage hypochromic red cells (%HRC) less than 6% (unless ferritin is greater than 800 µg/l/
• In practice it is likely this will require intravenous iron