Article Figures & Data
Figures
- FIGURE 2
Iron absorption and metabolism is controlled by several proteins.
DMT1 = divalent metal transporter 1; FPN = ferroportin; Hgb = hemoglobin; TF = transferrin, TFR = transferrin receptor
Tables
NHCT52 CHOIR53 CREATE54 TREAT55 Population Patients with chronic heart failure and end-stage renal disease on dialysis Chronic kidney disease Chronic kidney disease Chronic kidney disease with diabetes Hemoglobin target 10 vs 14 g/dL 13.5 vs 11.3 g/dL > 13 vs 11 g/dL > 13 vs 9 g/dL Target achieved? No No Yes No Primary outcomes Time to death or first myocardial infarction Composite of death, myocardial infarction, hospitalization for chronic heart failure, stroke Time to first cardiovascular event Composite of death or a cardiovascular event and death or end-stage renal disease Risks with higher hemoglobin level Trend toward increased risk of primary outcome resulted in early study interruption Increased risk of primary outcome Trend toward risk increase that was nonsignificant: no benefits No risk increase or reduction Other results Higher rate of thrombosis in high-target group Improved quality of life Higher rate of stroke NHCT = Normal Hematocrit Study,52 CHOIR = Correction of Hemoglobin and Outcomes in Renal Insufficiency trial,53 CREATE = Cardiovascular Risk Reduction by Early Anemia Treatment trial,54 TREAT = Trial to Reduce Cardiovascular Events With Aranesp Therapy55
Target hemoglobin Target ferritin Target transferrin saturation Chronic kidney disease > 10 g/dL > 100 ng/mL > 20% End-stage renal disease 10–11.5 g/dL 200–1,200 ng/mL 30%–50% Based on information in KDIGO Clinical Practice Guideline for Anemia in Chronic Kidney Disease. Kidney Int Suppl 2012; 2:279–335.
Cause Test Course of action Easily correctable causesx Iron deficiency Iron studies If low, replenish Vitamin B12 deficiency Vitamin B12 level If low, replenish Folate deficiency Folate level If low, replenish Hypothyroidism Thyroid-stimulating hormone level Manage hypothyroidism ACEi/ARB-induced anemia ACEi or ARB level Stop ACEi or ARB Potentially correctable causes Infection and inflammation Serum C-reactive protein level If elevated, check for and treat infection or inflammation Hyperparathyroidism Parathyroid hormone level Manage hyperparathyroidism Underdialysis Kt/V Improve dialysis efficiency Blood loss or hemolysis Reticulocyte count (look for high value) Endoscopy, colonoscopy, hemolysis screen Bone marrow disorder, pure red-cell aplasia Reticulocyte count (look for low value) Check anti-ESA antibodies, parvovirus polymerase chain reaction, consider bone marrow biopsy Noncorrectable causes Hemoglobinopathies Serum protein electrophoresis Hematology referral Bone marrow disorders Bone marrow biopsy Hematology referral ACEi = angiotensin-converting enzyme inhibitor, ARB = angiotensin II receptor blocker, Kt/V = dialyzer clearance of urea times dialysis time, divided by volume of distribution of urea
