Chronic Kidney Disease Pathway Document Description Presented ...

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• Malignancy • Haemolysis • Bone marrow infiltration • Pure red cell aplasia (Iron deficiency anaemia is the most common cause of anaemia either due to negative iron balance through blood loss (most commonly gastrointestinal or menstrual), inadequate nutritional intake, or related to poor gastrointestinal absorption). Check: • full blood count (if not already done) • serum ferritin • total iron binding capacity • B 12 and folate • Other investigations will be determined by the likely alternative diagnoses and cardiovascular effects of anaemia, e.g. thyroid function test, echocardiography, cause of GI bleeding Serum ferritin Serum ferritin levels may be used to assess iron deficiency in people with CKD. Because serum ferritin is an acute-phase reactant and frequently raised in CKD, the diagnostic cut-off value should be interpreted differently to non-CKD patients 4 . Iron-deficiency anaemia should be: • diagnosed in people with stage 5 CKD with a ferritin level of less than 100 micrograms/l • considered in people with stage 3 and 4 CKD if the ferritin level is less than 100 micrograms/l. In people with CKD who have serum ferritin levels greater than100 micrograms/l, functional iron deficiency, (and therefore those patients who are most likely to benefit from intravenous iron therapy) should be defined by: • percentage of hypochromic red cells greater than 6%, where the test is available, or • transferrin saturation less than 20%, when the measurement of the percentage of hypochromic red cells is unavailable. Supplements of vitamin C, folic acid or carnitine should not be prescribed specifically for the treatment of anaemia of CKD. 52
If all other causes for the anaemia have been excluded, (or where diagnosis is unclear) then referral may be indicated for assessment and possible initiation of Erythropoietin Stimulating Agent (ESA). References 1. El Achkar et al. Higher prevalence of anemia with diabetes mellitus in moderate kidney insufficiency: The <strong>Kidney</strong> Early Evaluation Program (KEEP). <strong>Kidney</strong> International 2005; 67: 1483-8. 2. National Health and Nutritional Examination Survey III (NHANES III) data cited in Royal College of Physicians. Anaemia Management in CKD: National Clinical Guideline for Management in Adults and Children. http://www.nice.org.uk/nicemedia/pdf/Anaemia_Management_full_guideline.pdf 3. NICE clinical guideline 39: Anaemia Management in People with CKD http://www.nice.org.uk/nicemedia/pdf/AMCKD_NICE_guideline_v8.1.pdf 4. Royal College of Physicians. Anaemia Management in CKD: National Clinical Guideline for Management in Adults and Children. http://www.nice.org.uk/nicemedia/pdf/Anaemia_Management_full_guideline.pdf Return to overview 53
Page 1 and 2: Chronic Kidney Disease Pathway Docu
Page 3 and 4: Pathway for the Identification and
Page 5 and 6: Contents Introduction …………
Page 7 and 8: Introduction Chronic kidney disease
Page 9 and 10: CKD Pathway D I A G N O S I S Ensur
Page 11 and 12: Kidney function deteriorates natura
Page 13 and 14: Joint Speciality Committee - Royal
Page 15 and 16: Acute Renal Failure Acute Renal Fai
Page 17 and 18: Next Steps Any patient suspected to
Page 19 and 20: Return to overview CKD Stages CKD S
Page 21 and 22: Practice Action Plan Compiling a Ch
Page 23 and 24: Action Rationale Responsible Run a
Page 25 and 26: eGFR
Page 27 and 28: CKD Stages CKD Stage Description Re
Page 29 and 30: References Joint Speciality Committ
Page 31 and 32: Cardiovascular Risk All patients wi
Page 33 and 34: Hypertension Blood pressure should
Page 35 and 36: Further information on the pharmaco
Page 37 and 38: Irbesartan* Valsartan Losartan* *Sp
Page 39 and 40: • Diuretics • Lithium carbonate
Page 41 and 42: Recommendation: Therefore consider
Page 43 and 44: Lower levels of proteinuria should
Page 45 and 46: Glycaemic Control CKD and Diabetes
Page 47 and 48: References Audit Commission (2002)
Page 49 and 50: Influenza and Pneumococcal Vaccine
Page 51: Stage 3 Management at stage 3 shoul
Page 55 and 56: Clinic inclusion criteria: Patients
Page 57 and 58: Where vitamin D supplementation is
Page 59 and 60: Stage 5 Patients identified at CKD
Page 61 and 62: Information to include with referra
Page 63 and 64: Appendix 1 The Dudley Group of Hosp

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