Nephrol Dial Transplant (2000) 15: 36-39
© 2000 European Renal Association-European Dialysis and Transplant Association
Management of early renal anaemia: diagnostic work-up, iron therapy, epoetin therapy
Department of Medicine, University of Arizona, Tucson, AZ, USA
Effective management of early anaemia in the course of chronic renal insufficiency requires the following: (i) implementing an efficient diagnostic strategy to exclude common contributing factors; (ii) initiating epoetin therapy for the majority of patients; and (iii) ensuring adequate iron supply for erythropoiesis.
Diagnostic inquiry is warranted whenever the haemoglobin concentration is below the normal range adjusted for age and gender. The most efficient diagnostic approach is to assume erythropoietin deficiency, exclude iron deficiency, and pursue further diagnostic tests only when red-cell indices are abnormal or when leukopenia or thrombocytopenia are also present. Macrocytosis should prompt an inquiry into alcoholism, B12 deficiency, or folate deficiency. Microcytosis suggests iron deficiency or thalassaemia. Associated cytopenias raise the possibility of alcohol toxicity, pernicious anaemia, malignancy, or myelo-dysplastic syndrome. Epoetin therapy is warranted whenever the haemoglobin concentration has fallen below 10.0 g/dl. To initiate therapy prior to dialysis, 100 IU/kg/week (80–120 IU/kg/week, 50–150 IU/kg/week) by subcutaneous injection. Haemoglobin concentration should be monitored every 2 weeks and the epoetin dose adjusted by increments or decrements of 25% to maintain a rate of rise of haemoglobin concentration of 0.2–0.6 g/dl (0.3–0.6 g/dl/week, 0.2–0.5 g/dl/week). When the target range is achieved, the dose of epoetin should be continually adjusted to maintain a stable haemoglobin concentration. Transferrin saturation and ferritin concentration should be monitored monthly, and sufficient iron provided to maintain transferrin saturation above 20%. The lower the haemoglobin concentration, the greater the likelihood that future intravenous iron will be required. Oral iron supplements should be avoided, since they are costly, ineffective, and troublesome to patients. Finally, a blunted therapeutic response to epoetin therapy provides important diagnostic information and should prompt renewed diagnostic inquiry.
Keywords: anaemia; epoetin; haemoglobin; iron status; uraemia
Correspondence and offprint requests to: David B. Van Wyck, Box 245099, Department of Medicine, Arizona Health Sciences Center, Tucson, AZ 85724, USA