Clinical Case Database / Category: Patient Management

Anaemia in chronic kidney disease: a pitfall

Publication details

Vijayan Suresh, Alvin Shrestha
Foundation Years Journal, volume 9, issue 5, p.10 (123Doc Education, London, May 2015)

Abstract

Anaemia is common in chronic kidney disease (CKD), and the prevalence increases as the glomerular filtration rate (GFR) progressively falls (1). Using the World Health Organisation criteria for anaemia of haemoglobin (Hb) less than 13 g/dl in men and less than 12 g/dl in women, 15.3% of patients with CKD 3 to 5 were anaemic in a UK population (2). Higher or normal Hb levels are associated with reduced hospitalisation, less severe left ventricular hypertrophy and improved quality of life, up until Hb of 13 g/dl is achieved (where anything above is associated with worse outcome (3)) which makes it important to recognise and treat.
The mechanism of anaemia in CKD is multifactorial, including impaired erythropoietin synthesis, haematinic deficiency and anaemia of chronic disease. Iron deficiency may occur due to reduced absorption from the gut, due to inflammation (4) which is common in CKD. This is thought to be associated with inflammatory cytokines inducing hepcidin transcription, which inhibits iron absorption (5). Functional iron deficiency can also occur due to the use of erythropoesis stimulating agents (ESAs) which deplete the iron pool by increasing erythropoeisis (5), often defined by a transferrin saturation (TSAT) of below 20% (6).
Guidelines such as the National Institute for Clinical Excellence (NICE) recommend the need for replenishing iron stores before commencing ESA therapy in those who are iron deficient (7). However, it is important to remember that iron deficiency is also an important manifestation of gastrointestinal (GI) malignancy and other GI bleeding lesions. Upper GI malignancy was reported as 5.5% and lower GI malignancy 10% in the presence of iron deficiency anaemia (IDA), in one study (8).

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Authors

Vijayan Suresh

Consultant Nephrologist, Department of Renal Medicine
Heart of England NHS Foundation Trust, Birmingham, B9 5SS
vijayan.suresh@heartofengland.nhs.uk

Alvin Shrestha (Corresponding author)

CMT Doctor, Department of Renal Medicine
Heart of England NHS Foundation Trust, Birmingham, B9 5SS
alvinshrestha@gmail.com

References

1. Hsu CY, McCulloch CE, Curhan GC. Epidemiology of anemia associated with chronic renal insufficiency among adults in the United States: results from the Third National Health and Nutrition Examination Survey. J Am Soc Nephrol. 2002; 13: 504-510.
2. de Lusignan S, Chan T, Stevens P et al. Identifying patients with chronic kidney disease from general practice computer records. Fam Pract. 2005; 22: 234-241.
3. KDOQI; National Kidney Foundation Clinical practice guidelines and clinical practice recommendations for anemia in chronic kidney disease in adults. Am J Kidney Dis. 2006; 47(5 Suppl 3): S16-85.
4. Andrews NC. Anemia of inflammation: the cytokine-hepcidin link. J Clin Invest. 2004; 113(9): 1251-1253.
5. Babitt J, Lin H. Mechanisms of anemia in CKD. J Am Soc Nephrol. 2012; 23: 1631-1634.
6. Wish J. Assessing iron status: beyond serum ferritin and transferrin saturation. Clin J Am Soc Nephrol. 2006; 1(Suppl 1): S4-8.
7. NICE. Anaemia management in people with chronic kidney disease. NICE clinical guideline 114. 2011 (cited 2014 July 8) Available from www.guidance.nice.org.uk/cg114
8. Powell N, McNair A. Gastrointestinal evaluation of anaemic patients without evidence of iron deficiency. Eur J Gastroenterol Hepatol. 2008; 20(11): 1094-1100.
9. Bosman DR, Winkler AS, Marsden JT, Macdoughall IC, Watkins PJ. Anemia with erythropoietin deficiency occurs early in diabetic nephropathy. Diabetes Care. 2001; 24(3): 495-9.
10. Goddard AF, James MW, McIntyre AS et al; British Society of Gastroenterology. Guidelines for the management of iron deficiency anaemia. Gut. 2011; 60: 1309-1316.
11. Niv E, Elis A, Rivka Z et al. Iron deficiency anaemia in patients without gastrointestinal symptoms – a prospective study. Fam Pract. 2005; 22: 58-61.

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