KDOQI GUIDELINE 8 ASSOCIATION OF LEVEL OF GFR WITH ANEMIAWord文件下载.docx
- 文档编号:16421276
- 上传时间:2022-11-23
- 格式:DOCX
- 页数:10
- 大小:334.46KB
KDOQI GUIDELINE 8 ASSOCIATION OF LEVEL OF GFR WITH ANEMIAWord文件下载.docx
《KDOQI GUIDELINE 8 ASSOCIATION OF LEVEL OF GFR WITH ANEMIAWord文件下载.docx》由会员分享,可在线阅读,更多相关《KDOQI GUIDELINE 8 ASSOCIATION OF LEVEL OF GFR WITH ANEMIAWord文件下载.docx(10页珍藏版)》请在冰豆网上搜索。
Anemiausuallydevelopsduringthecourseofchronickidneydiseaseandmaybeassociatedwithadverseoutcomes.
∙PatientswithGFR<
60mL/min/1.73m2shouldbeevaluatedforanemia.Theevaluationshouldincludemeasurementofhemoglobinlevel.
∙Anemiainchronickidneydiseaseshouldbeevaluatedandtreated—seeKDOQIClinicalPracticeGuidelinesforAnemiaofChronicKidneyDisease,Guidelines1through4,asshowninFig25.
Figure25
Anemiawork-upforpatientswithchronickidneydisease.Modifiedandreproducedwithpermission.265,266
(Clickonimagetoenlarge)
BACKGROUND
Itiswellestablishedthatanemiadevelopsinthecourseofchronickidneydiseaseandisnearlyuniversalinpatientswithkidneyfailure.264Thedevelopmentofeffectivetherapeuticoptions,suchaserythropoietintherapy,hasprovidedfortheeffectivetreatmentofanemia.AnearlierKDOQIclinicalpracticeguidelineisdevotedtothistopic265,266;
however,thatguidelinefocusedprimarilyonpatientstreatedbydialysis.Thisguidelineaddressesanemiaintheearlierstagesofchronickidneydisease.
Importantly,pastguidelineshavereliedonserumcreatininelevels>
2mg/dLasthecriteriontotestforthepresenceofanemia.TheWorkGrouprecommendsthattheKDOQIAnemiaguidelinebeupdatedtoincorporateestimatedGFR<
60mL/min/1.73m2totriggertheascertainmentofanemia,ratherthanthepreviouslycitedserumcreatininelevels(Fig25).
RATIONALE
DefinitionofAnemia
Measuresusedtoassessanemiaanditscausesincludehemoglobin,hematocrit,andironstores(asmeasureddirectlybybonemarrowbiopsy,orindirectlyasmeasuredbyserumferritin,transferrinsaturationlevels,andpercentageofhypochromicredbloodcellsorreticulocytes).Erythropoietinlevelsarelessusefulasameasureofanemiainchronickidneydisease,sinceitisnowwellestablishedthattheyareoftennotappropriatelyelevateddespitelowhemoglobinlevels.267-271
Measurementofhemoglobin,ratherthanhematocrit,isthepreferredmethodforassessinganemia.Unfortunately,thisissuehasbeenconfusedduetotheuseofhematocritinanumberofstudies.Hematocritisaderivedvalue,affectedbyplasmawater,andthussubjecttoimprecisionasadirectmeasureoferythropoiesis.Measurementofhemoglobingivesanabsolutevalueand,unlikehematocrit,isnotaffectedgreatlybyshiftsinplasmawater,asmayoccurwithdiureticsorwithdialysistherapy.Hemoglobinlevelsaredirectlyaffectedbylackoferythropoietinproductionfromthekidneyandthusserveasamoreprecisemeasurementoferythropoiesis.
Whiledecreasedhemoglobinoftenaccompanieschronickidneydisease,thereisnoquantitativedefinitionofanemiainchronickidneydisease,since"
acceptable"
(normal)hemoglobinlevelshavenotbeendefinedforpatientswithkidneydisease.Instead,anemiaisdefinedaccordingtophysiologicalnorms.Allpatientswithchronickidneydiseasewhohavehemoglobinlevelslowerthanphysiologicalnormsareconsideredanemic.
Thedefinitionofanemiainchronickidneydiseaseisfurthercomplicatedbygenderdifferencesinhemoglobinlevels.Inthenormalpopulation,hemoglobinlevelsvarybetweengendersandalsoasafunctionofmenopausalstatus.TheWorldHealthOrganizationdefinesanemiatobethatlevelofhemoglobinandgender-determinednormalrangeswithoutreferencetoageormenopausalstatus.272Thus,formales,anemiaisdefinedashemoglobinlevel<
13.0g/dL,whileinwomen,anemiaisdefinedashemoglobinlevel<
12.0g/dL.TheWHOisintheprocessofupdatingthesedefinitionstoexpandandrefinethemwithspecificlevelsinpregnantwomenandchildrenofdifferentages.Inmoststudiesofanemiarelatedtothelevelofkidneyfunction,theseissueshavenotbeentakenintoaccount.
Theoperationaldefinitionofanemiainpatientswithkidneydiseasehasalsobeeninfluencedbyhealthpolicy.Inthepast,nationalreimbursements(suchasMedicareandMedicaidintheUnitedStates)haverequiredtheattainmentofspecificlevelsofhemoglobinorhematocrit,leadinginvestigatorsandclinicianstodefineanemiarelativetothoseregulatorylevels.AsstatedintheEuropeanBestPracticeGuidelinesfortheManagementofAnaemia,273itisimportanttodefineanemiarelativetophysiologicalnormsratherthanpaymentrules.
Somestudieshavearbitrarilydefinedthe"
anemia"
ofkidneydiseaseasahemoglobinlevelbelowsomediscretionarylevel(eg,10g/dL)thatiswellbelowthenormativevaluesinthegeneralpopulation.Thelowhemoglobinlevelthatisoftenseeninchronickidneydiseaseshouldnotleadtotheacceptanceoflowerthannormalhemoglobinlevelsasappropriateinpatientswithchronickidneydisease.
StrengthofEvidence
Anemiadevelopsduringthecourseofchronickidneydisease(R).Lowerhemoglobinmayresultfromthelossoferythropoietinsynthesisinthekidneysand/orthepresenceofinhibitorsoferythropoiesis.Numerousarticlesdocumenttheassociationofanemiawithkidneyfailureanddescribeitsvariouscauses.267,268,274-276Theseverityofanemiainchronickidneydiseaseisrelatedtothedurationandextentofkidneyfailure.Thelowesthemoglobinlevelsarefoundinanephricpatientsandthosewhocommencedialysisatveryseverelydecreasedlevelsofkidneyfunction.271,277,278
Anemiaisassociatedwithworseoutcomesinchronickidneydisease(R).Asyetitisundeterminedwhetherthepresenceofanemiainchronickidneydiseasedirectlyworsensprognosisorwhetheritisamarkerfortheseverityofotherillnesses.Definitivestudieshavenotbeenconcluded.Theavailableevidence,consistingoflargedatabaseanalysisandpopulationstudies,clearlyshowthatlowhemoglobinlevelsareassociatedwithhigherratesofhospitalizations,cardiovasculardisease,cognitiveimpairment,andotheradversepatientoutcomes,includingmortality.279-284
Erythropoietindeficiencyistheprimarycauseofanemiainchronickidneydisease(R).Anemiainpatientswithchronickidneydiseaseisduetoanumberoffactors,themostcommonofwhichisabnormallylowerythropoietinlevels.Othercausesinclude:
functionalorabsoluteirondeficiency,bloodloss(eitheroccultorovert),thepresenceofuremicinhibitors(eg,parathyroidhormone,spermine,etc),reducedhalflifeofcirculatingbloodcells,deficienciesoffolateorVitaminB12,orsomecombinationofthesewithadeficiencyoferythropoietin.267-269,274,275Patientswithkidneydiseasemayhaveconcurrentunderlyinghematologicalproblemssuchasthalassemiaminor,sicklecelldisease,oracquireddiseasessuchasmyelofibrosisoraplasticanemia.
Thecausativeroleoferythropoietindeficiencyinanemiaofchronickidneydiseaseincludes:
(1)anemiaisresponsivetotreatmentwitherythropoietininallstagesofchronickidneydisease;
and
(2)inpatientswithchronickidneydisease,circulatinglevelsoferythropoietinarenotsufficienttomaintainhemoglobinwithinthenormalrange.NorthAmerican(UnitedStatesandCanada)andEuropeanstudieshavedemonstratedthesepoints.270,271,282,285-287
OnsetandseverityofanemiaarerelatedtothelevelofGFR;
belowaGFRofapproximately60mL/min/1.73m2,thereisahigherprevalenceofanemia(Tables76and77andFigs26,27,28,and29)(C,S).
Figure26
BloodhemoglobinpercentilesbyGFRadjustedtoage60(NHANESIII).Medianand5thand95thpercentilesofhemoglobinamongadultparticipantsage20yearsandolderinNHANESIII,1988to1994.Valuesareadjustedtoage60yearsusingapolynomialquantileregression.TheestimatedGFRforeachindividualdatapointisshownwithaplussign(+)neartheabscissa.95%confidenceintervalsatselectedlevelsofestimatedGFRaredemarcatedwithtriangles,squares,andcircles.
Figure27
AdjustedprevalenceinadultsoflowhemoglobinbyGFR(NHANESIII).Predictedprevalenceofhemoglobin<
11and<
13g/dLamongadultparticipantsage20yearsandolderinNHANESIII,1988to1994.Valuesareadjustedtoage60yearsusingapolynomialregression.95%confidenceintervalsareshownatselectedlevelsofestimatedGFR.
Figure28
HemoglobinpercentilesbyGFR.Thesedataarebasedontheresultsof446patientsenrolledintheCanadianMulticentreLongitudinalCohortstudyofpatientswithchronickidneydisease.Allpatientswerereferredtonephrologistsbetween1994and1997.Nopatientwasreceivingerythropoietintherapyatthetimeofenrollment,andnopatienthadanAVfistula.Adaptedandreprintedwithpermission.288
Figure29
PrevalenceoflowhemoglobinbyGFRcategory.Thesedataarebasedontheresultsof446patientsenrolledintheCanadianMulticentreLongitudinalCohortstudyofpatientswithchronickidneydisease.Allpatientswerereferredtonephrologistsbetween1994and1997.Nopatientwasreceivingerythropoitentherapyatthetimeofenrollment,andnopatienthadanAVfistula.Adaptedandreprintedwithpermission.288
Studiesreviewedforthepurposesofthisguidelineincludethoseofpatientswithchronickidneydiseasepriortodialysis,thosewithkidneytransplants,andthoseondialysis.
Thereviewedliteraturespansalmost30yearsofinvestigationanddescribestheclinicalfindingsofresearchersastheyexploretherelationshipsbetweenhemoglobinandkidneyfunction(Tables76and77).Themajorityofavailabledatahavebeende
- 配套讲稿:
如PPT文件的首页显示word图标,表示该PPT已包含配套word讲稿。双击word图标可打开word文档。
- 特殊限制:
部分文档作品中含有的国旗、国徽等图片,仅作为作品整体效果示例展示,禁止商用。设计者仅对作品中独创性部分享有著作权。
- 关 键 词:
- KDOQI GUIDELINE ASSOCIATION OF LEVEL GFR WITH ANEMIA
链接地址:https://www.bdocx.com/doc/16421276.html