Erythropoietin Resistance in Patients with Chronic Kidney Disease: Current Perspectives

Figures & data

Table 1 Current Recommendations on the Treatment of Anemia - KDIGO (2012)

				Stages of Chronic Renal Disease
				3	4	5	5D
Investigation of Anemia				Complete blood count Absolute reticulocyte count Serum ferritin and transferrin saturation (TSAT) Serum vitamin B12 and folate levels
Diagnosis of Anemia				Adults and children aged >15 years: Hb concentration of <13.0 g/dl for males and <12.0 g/dl for females Children: Hb concentration of <11.0 g/dl for ages 0.5–5 years, <11.5 g/dl for ages 5–12 years, and <12.0 g/dl for ages 12–15 years
Monitoring	Not anemic (when clinically indicated and …)			Annually	Twice per year		Every 3 months
	Anemic but not on EAS (when clinically indicated and …)			Every 3 months			HD: Monthly PD: Every 3 months
Drug Treatment	Iron agents		Initiation	Adults: TSAT < 30% and ferritin < 500 mcg/l Children: TSAT <20% and ferritin <100 mcg/l			TSAT< 20% and ferritin < 100 μ/L
			Maintenance	Based on Hb responses to recent iron therapy and ongoing blood losses, iron status tests (TSAT and ferritin), Hb concentration, ESA responsiveness and ESA dose in ESA-treated patients, trends in each parameter, and the patient’s clinical status
	EAS	Initiation		Adults with Hb concentrations of <10.0 g/dl and for all pediatric patients with consideration of potential benefits and harms			When the Hb concentration is between 9.0 and 10.0 g/dl
		Maintenance		Based on the patient’s Hb concentration, rate of change in Hb concentration, current ESA dose, and clinical circumstances Pediatric: ESA therapy aimed at a range of 11.0 to 12.0 g/dl Use of iron indexes to help guide therapy, with considerations of infection risk from excess iron and suboptimal ESA responsiveness
		Hyporesponsiveness	Diagnosis (Initial)	No increase in Hb concentration from baseline after the first month of ESA treatment on appropriate weight-based dosing
			Diagnosis (Subsequent)	After treatment with stable doses of ESA, patients require 2 increases in ESA doses up to 50% beyond the dose at which they had been stable to maintain a stable Hb concentration
			Management	Treatment for specific causes of poor ESA response Individualization of therapy, accounting for relative risks and benefits
	Precautions			Administration of IV iron is avoided in patients with active systemic infections Monitoring for 60 minutes after IV iron infusion Addressing correctable causes of anemia prior to initiation ESA therapy ESA therapy not to be used to intentionally increase the Hb concentration to >13 g/dl ESAs are to be used with caution in patients with a history of malignancy, active malignancy, and a history of stroke

Notes: Data from Kidney Disease Improving global outcomes Anemia work group.⁸

Kidney Disease Improving global outcomes Anemia work group. KDIGO clinical practice guideline for anemia in chronic kidney disease. Kidney Int Suppl. 2012;2(4):279–335. doi:10.1038/kisup.2012.37.

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