Anemia Guideline

Guiding Principles

Patients with Advanced Chronic Kidney Disease (ACKD) are at risk of anemia which can contribute to fatigue and breathlessness. Common management strategies include the use of erythropoiesis stimulating agents and iron supplementation. Blood work related to anemia is typically done monthly for ACKD patients; this could be decreased to every 3 months for patients receiving conservative kidney management but should be based on patient preference and symptoms.

Use registered dietitians or accredited nutrition providers to provide information for people with ACKD about dietary adaptations regarding sodium, phosphorus, potassium, and protein intake, tailored to their individual needs, and severity of ACKD and other comorbid conditions, where available.

For patients receiving conservative kidney management, the primary goal of anemia management is to optimize function and quality of life compatible with level of frailty. Individualization is key

GFR 15 - 5 | Slow Decline/Deteriorating | Last 0-5 years of life

For patients receiving Conservative Kidney Management, anemia is treated with the goal of decreasing fatigue and dyspnea, as opposed to reducing cardiac mortality or morbidity.

Interventions should be continued only for so long as they are of symptomatic benefit. It should be explained to patients and caregivers early on that there may come a time when the interventions no longer benefit the patient, at which time they would be stopped.

GFR 5 - 0 | Intensive/Near Death | Last 0-2 months of life

As the patient nears the end of life, it is no longer appropriate to manage fatigue and dyspnea via these interventions and they should be stopped. Providing supportive care to address fatigue and using medications such as opioids to manage dyspnea are appropriate interventions at this time.

Objectives

  • To achieve adequate hemoglobin and iron levels in kidney failure patients who have true iron deficiency and anemia resulting from their kidney disease
  • Note that interventional guidelines do not replace individualized care and clinical expertise

TSAT (Transferrin Saturation) 20% to 49%

  • This is considered iron-replete; maintain iron stores

TSAT (Transferrin Saturation) less than 20%

  • If patient’s iron stores are low and if patient is not already on oral iron supplement, contact most responsible healthcare provider to consider low dose therapy
  • If receiving oral iron, increase to next incremental tolerated dose (see below)
  • An IV iron regime may be considered if the patient is unable to tolerate or reach target levels with oral iron (see below)

Intermittent IV iron infusion – Adults Venofer (iron sucrose)

  • Administer usual concentrations up to 2 mg/mL (mixed in Normal Saline) but higher concentrations may be used
  • Infuse over the following time periods:
    • 200mg or less; at least 15 minutes
    • 300mg; at least 90 minutes
    • 400mg; at least 150 minutes
    • 500mg; at least 210 minutes

 

Drug Elemental Iron/Tablet Dose Adjustment Increment (increase or decrease by) Maximum dose
Note: Oral iron may cause constipation
*Proferrin consists of a blood product (heme iron peptide) made from animal haemoglobin and should NOT be taken if allergic to meat products of if animal or blood-based products are not allowed in the diet (i.e., vegan, Jehovah Witness)
(adapted from AHS Anemia Management Guideline (June 2017), Alberta Kidney Care (AKC) - CKD, PD, HD Programs)
Polysaccharide Iron Complex 150 mg/150 mg 150 mg tablet 300 mg/day
Ferrous Sulfate 60 mg/300 mg 300 mg tablet 900 mg/day
Ferrous Fumerate 100 mg/300 mg 300 mg tablet 600 mg/day
Ferrous Fumerate (liquid) 100 mg/5 mL 5 mL 10 mL/day
Ferrous Gluconate 35 mg/300 mg 300 mg tablet 900 mg/day
Proferrin* 11 mg/11 mg 11 mg tablet 33 mg/day

General Guidelines:

  1. Target Hgb: 95 – 110 g/L
  2. Notify most responsible health care provider when:
    • Hgb drops > 20 g/L over 3 months
    • Hgb remains out of target after more than 3 frequency changes
  3. If Hgb greater than 120 g/L, hold darbepoetin
  4. Maximum dose of darbepoetin is 150 mcg subcutaneously q2 weeks
  5. Note: darbepoetin is to be administered SC

Correct iron deficiency first; this is required for AB Blue Cross funding for darbepoetin.

< 70 kg 40 mcg q2 weeks
70 – 100 kg 60 mcg q2 weeks
> 100 kg 80 mcg q2 weeks

IF Hgb ≤95 g/L and increased ≤10 g/L over the previous 3 months, increase frequency or dose.

IF Hgb ≤95 g/L and increase was between 10-20 g/L, do not change dose.

Current Frequency: Change To:
q2 weeks Increase dose
q3 weeks q2 weeks
q4 weeks q3 weeks

IF Hgb ≥110 g/L or if Hgb is between 95-110 g/L and this has risen by > 20 g/L over the previous 3 months, decrease frequency or dose.

Current Frequency: Change To:
q2 weeks q3 weeks
q3 weeks q4 weeks
q4 weeks decrease dose

Instructions:

  1. To increase dose, move down one box.  To decrease dose, move up one box
  2. IF the patient's scenario does not fall into one of the examples above, contact the nephrologist or designate
  3. Maximum epoetin alpha (Eprex ®) dose is 15,000 IU weekly
  4. Epoetin alpha (Eprex ® ) should not be increased by greater than 30% at any given time (dose decreases may be greater than 30%)
  5. Epoetin alpha to be administered SC