Kidney disease, chronic iron therapy

FIGURE 76-5. Guidelines for iron therapy in the management of the anemia of chronic kidney disease (CKD). (CHr, content of hemoglobin in the reticulocytes ESA, erythropoietic-stimulating agent Hb, hemoglobin HD, hemodialysis PD, peritoneal dialysis TSat transferrin saturation.)... 

Patients with anemia secondary to chronic kidney disease are ideal candidates for epoetin alfa therapy. The response in predialysis, peritoneal dialysis, and hemodialysis patients is dependent on the severity of renal failure, erythropoietin dose and route of administration, and iron availability. The subcutaneous route of administration is preferred to the intravenous route because absorption is slower and the amount of drug required is reduced by 20 to 40%. 

Recombinant erythropoietin therapy, in conjunction with adequate iron intake, can be highly ejfective in a number of anemias, especially those associated with a poor erythropoietic response. There is a clear dose-response relationship between the epoetin alfa dose and the rise in hematocrit in anephric patients. Epoetin alfa is effective in the treatment of anemias associated with surgery, AIDS, cancer chemotherapy, prematurity, and certain chronic inflammatory conditions. Darbepoetin alfa also is approved for use in patients with anemia associated with chronic kidney disease and is under review for several other indications. 

Anemia is also an independent risk factor for progression of chronic renal failure. The anemia of CKD is, in most patients, normocytic and normochromic, and is due primarily to reduced production of erythropoietin (EPO) by the kidney (a presumed reflection of the reduction in functioning renal mass), low iron stores and shortened red cell survival. In 40%, it could be corrected by iron replacement. Early initiation of EPO therapy in patients with CKD and mild to moderate anemia significantly slowed down the progression of renal disease and delayed the need for renal replacement therapy. The target level of hemoglobin is llOg/1 [10],... 

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