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NICE guidelines on managing anaemia in kidney disease

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VOL: 102, ISSUE: 41, PAGE NO: 23

Terry Hainsworth, BSc, RGN, is clinical editor, Nursing Times

The National Institute for Health and Clinical Excellence and the National Collaborating Centre for Chronic Conditi...

The National Institute for Health and Clinical Excellence and the National Collaborating Centre for Chronic Conditions (2006) have issued clinical guidance to improve care for people with anaemia associated with chronic kidney disease (NT News, 3 October, p7).

Chronic kidney disease is a long-term condition that ranges from 'almost undetectable' - where the main risk is cardiovascular disease - to 'severe', where renal failure is fatal without dialysis or a kidney transplant (Department of Health, 2005). The National Service Framework for Renal Services (DH, 2005) has adopted the US National Kidney Foundation's Kidney Disease Outcomes Quality Initiative classification of the disease, which outlines five stages defined by kidney damage and level of renal function as measured by glomerular filtration rate (Table 1, p24).

There have been recent international studies into the prevalence of the disease (DH, 2005). The new guidelines (National Collaborating Centre for Chronic Conditions, 2006) report US prevalence figures suggesting that overall 11% of the population have some degree of kidney disease (National Center for Health Statistics, 2005). A similar population prevalence of stage 3-5 disease has been described for England (De Lusignan, et al, 2005).

Anaemia in chronic kidney disease

As well as the filtration of waste products the kidneys also produce the growth factor erythropoietin, which regulates red blood cell synthesis. Anaemia is therefore a common result of chronic renal failure (Campbell, 2005) and although chronic kidney disease is not the most common cause of anaemia in the UK, prevalence of anaemia in patients with the disease is high (Campbell, 2003).

It is now understood that anaemia begins to develop early in the condition (National Collaborating Centre for Chronic Conditions, 2006) and that lower levels of kidney function are associated with lower haemoglobin levels and a higher prevalence and severity of anaemia (National Center for Health Statistics, 2005).

Anaemia in chronic kidney disease is important because it contributes significantly to the heavy symptom burden of the condition and is potentially reversible with appropriate treatment, including erythropoietin (National Collaborating Centre for Chronic Conditions. 2006).

Erythropoietin has been available in synthetic form for treating this type of anaemia since 1989. However, erythropoietin is expensive, its use can be complicated and it is often not the only therapy required for optimal treatment of (National Collaborating Centre for Chronic Conditions. 2006).

The guidelines

This new guidelines (National Collaborating Centre for Chronic Conditions, 2006) highlight best practice in the care of people with anaemia resulting from chronic kidney disease. They include:

- Diagnostic evaluation and assessment of anaemia;

- Management of anaemia;

- Assessment and optimisation of erythropoiesis;

- Monitoring treatment.

As with other NICE guidance there is a significant emphasis on patient-centred care. This particularly focuses on treatment with erythropoiesis-stimulating agents so that patients are fully informed about the benefits and side-effects of such treatment and the consequences of poor concordance.

To this end the importance of culturally and age-appropriate patient education programmes for those diagnosed with anaemia of chronic kidney disease and their families and carers is stressed. It is suggested that this education may need to be repeated according to the changing circumstances of the patient. Coordination of care is highlighted as another important area both in terms of ensuring that responsibilities are clear across primary and secondary care and that patients have access to a designated contact person who responsibility for managing their anaemia.

The guidelines also stress that not all anaemia in patients with chronic kidney disease will be renal anaemia and other causes must be investigated and excluded.

Practice implications

Treatment and care should always take into consideration patients' individual needs and preferences and therefore people with anaemia associated with chronic kidney disease should have the opportunity to make informed decisions about their care and treatment.

The guidelines state that good communication between healthcare professionals and patients is essential and highlight the need for agreeing a plan for erythropoiesis-stimulating agent treatment between the clinician and the patient.

It is suggested that in agreeing such a plan the following factors should take into account:

- Continuity of drug supply;

- Flexibility of where the drug is delivered and administered;

- 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.

The other key recommendations within the guidance that have been identified as priorities for implementation include:

- Anaemia management should be considered when their haemoglobin (Hb) level is less than or equal to 11g/dl (or 10g/dl if younger than two years of age);

- Treatment with erythropoiesis-stimulating agents should be offered to people who are likely to benefit in terms of quality of life and physical function;

- Haemoglobin treatment and action thresholds should aim to maintain stable Hb levels between 10.5 and 12.5g/dl for adults and children older than two years, and between 10 and 12g/dl in children younger than twoyears, reflecting the lower normal range in that age group;

- Age alone should not be a determinant for treatment of anaemia associated with chronic kidney disease;

- Iron supplementation should be given in addition to erythropoiesis-stimulating agents to maintain serum ferritin levels between 200 and 500mcg/l in both haemodialysis and non-haemodialysis patients, and either transferrin saturation levels above 20% (unless ferritin is greater than800mcg/l) or percentage hypochromic red cells (%HRC) less than 6% (unless ferritin is greater than 800mcg/l). It is noted that in practice it is likely this will require intravenous iron.

The Future

Following review of the evidence for these guidelines the guideline development group has recommended further research, including:

- The use of intravenous iron in children;

- Trials of erythropoiesis-stimulating agents in children;

- Haemoglobin levels in older people;

- Erythropoiesis-stimulating agents tolerance tests;

- The assessment of iron levels in predialysis patients.

NICE is in the process of developing guidance for chronic kidney disease with expected publication in September 2008 and on erythropoietin for anaemia induced by cancer treatment at a publication date yet to be confirmed (NICE, 2006).

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