New Perspectives in Chronic Renal InsufficiencyDefining a renal anemia management period☆,☆☆
Section snippets
Overview
In nephric anemic dialysis patients, the mean baseline values of EPO (19 to 30 mU/mL) are much lower than those observed in healthy patients with the same degrees of anemia. Thus, although the kidney at end-stage renal disease (ESRD) continues to produce some EPO despite effective cessation of excretory function, it is incapable of augmenting EPO production in response to an appropriate hypoxic stimulus.4 Although few data are available on sequential EPO levels in patients with CRI, EPO
Pathogenesis
The persistent observations of “inappropriately” low EPO levels in virtually all cases of kidney disease14 indicate that the predominant factor in the anemia of kidney failure is the inadequate production of endogenous EPO by diseased kidneys. Shortened RBC survival may also play a role but is probably more instrumental in determining the severity of anemia. Kidney disease thus affects the RBC mass by interfering with both RBC production and life span through disruption of the kidney’s
The manifestations and implications of anemia in CRI
Very few studies have directly addressed the manifestations and implications of anemia in CRI. This may be because it is almost impossible to distinguish between the clinical effects of anemia and those due to mild azotemia and because anemia and the other concurrent comorbidities of CRI (eg, disturbances in divalent ion metabolism or subtle imbalances in electrolyte or acid-base status) can impact negatively on clinical status. Partial information, however, can be gleaned from longitudinal
The renal anemia management period (RAMP) and the impact of treatment
As described, the anemia of CRI is prevalent, occurring in a significant percentage of CRI patients; it is underrecognized, as a significant percentage of patients entering treatment for ESRD are also anemic (sometimes severely so); and it is undertreated, in that anemia responds to currently available therapeutic options that apparently are not being used often or effectively enough. Consequently, we propose the establishment and widespread recognition of a RAMP, defined as the period of time
Unanswered questions and research needs
There has been a strong tendency, as noted by Lindberg et al in this supplement (pp. S52-S61), to extrapolate results from rHuEPO trials in hemodialysis patients to other patient populations. In this era of evidence-based medicine, therapeutic and economic decisions based on such extrapolations clearly are no longer acceptable. The research agenda of the next decade must address questions that are unique to the anemia of CRI patients: What is the definition of anemia in patients with kidney
Conclusion
Anemia, an underrecognized and undertreated concomitant of CRI, is associated with significant clinical and functional consequences. Moreover, during the CRI period there is strong evidence for detrimental effects on QOL, exercise tolerance, and related factors that impact activities of daily living. In addition, it is indirectly linked to cardiac morphologic and functional changes, most specifically LVH and progression of LVMI abnormalities.
However, the most ominous effect of the anemia of CRI
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Cited by (49)
Roxadustat (FG-4592) treatment for anemia in dialysis-dependent (DD) and not dialysis-dependent (NDD) chronic kidney disease patients: A systematic review and meta-analysis
2020, Pharmacological ResearchCitation Excerpt :Although individual clinical trials conducted so far have shown the benefits of roxadustat, this systematic review and meta-analysis the totally of evidence for use of roxadustat in the treatment of anemia in CKD patients. anemia is a complication of CKD and associated with increased risk of death and complications [39]. Despite a high prevalence, it remains significantly undertreated worldwide, especially in those not dependent on dialysis partly due to safety concerns about the use of ESAs.
Bone Marrow Iron in CKD: Correlation With Functional Iron Deficiency
2010, American Journal of Kidney DiseasesThe influence of anemia on clinical presentation and outcome of patients with first-ever atherosclerosis-related ischemic stroke
2009, Journal of Clinical NeuroscienceCitation Excerpt :We found that in patients with anemia, the age at disease onset was older than patients without, which was similar to Kiyohara’s study.25 Chronic renal insufficiency occurred more frequently in patients with anemia, which may relate to decreased erythropoietin secretion in patients with chronic renal insufficiency.30–32 There was no significant difference between groups with regard to the risk of stroke recurrence within 3 years after the onset of first-ever ischemic stroke.
Chronic Kidney Disease and Its Complications
2008, Primary Care - Clinics in Office PracticeCitation Excerpt :In CKD, tubular atrophy generates tubulointerstitial fibrosis, which compromises renal erythropoietin synthetic capacity and results in anemia. The anemia of CKD increases morbidity and mortality from cardiovascular complications (angina, left ventricular hypertrophy [LVH], and worsening heart failure) [7], which may lead to further deterioration of renal function and the establishment of a vicious cycle termed the “cardiorenal anemia syndrome.” The presence of LVH is associated with decreased survival of patients on dialysis.
Optimal anemia management reduces cardiovascular morbidity, mortality, and costs in chronic kidney disease
2005, Kidney InternationalCitation Excerpt :Both the NKF-DOQI and the European Best Practice Guidelines establish a minimum threshold hemoglobin of 11 g/dL for evaluation and intervention, but the latter also features an open-ended target hemoglobin that provides for normalization of hemoglobin where clinically appropriate42. Because of the growing body of scientific literature on the significant morbidity and mortality associated with the anemia of chronic kidney disease, a Renal Anemia Management Period (RAMP) has been proposed43. The RAMP is defined as the time following onset of chronic kidney disease when anemia develops, and needs early diagnosis and treatment, which would achieve the goals of delaying disease progression, minimizing cardiovascular complications, and enhancing quality of life.
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Supported by an unrestricted educational grant from Amgen, Inc.
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Address reprint requests to Anatole Besarab, MD, Professor of Medicine, West Virginia University Department of Medicine, Robert C. Byrd Health Science Center, PO Box 9165, Morgantown, WV 26506. E-mail: [email protected]