Anaemia Management in CKD

For further information regarding anaemia in renal disease, click here to visit the textbook page.

Iron and ESA therapy in CKD and Peritoneal Dialysis

For conservative care patients, those on peritoneal dialysis, and those who have not yet commenced haemodialysis, Monofer® is currently the preferred IV preparation. Treatment of these patients are managed by our Anaemia Co-ordinators, who can be contacted on 0131 242 1204. To download the current protocol for IV Monofer, please click here.

Community-based patients, such as those with advanced CKD, pre-dialysis patients and those on peritoneal dialysis, can receive ESA therapy from the hospital or their GP via a Shared Care Agreement. This type of ESA therapy is usually given subcutaneously, and the current ESA of choice is Mircera®.

Iron and ESA therapy in Haemodialysis

Diafer® is currently the IV iron preparation of choice for haemodialysis patients within NHS Lothian. Dosing is patient dependent, but most patients will receive either 50 or 100mg on a weekly, fortnightly, or monthly basis during their dialysis sessions. Iron stores are checked once every 3 months, although more frequent monitoring may be necessary for some patients.

Haemodialysis patients who require ESA therapy will receive Neorecoromon®. See tablet below for guidance regarding initiation of ESA therapy in haemodialysis patients.

Quick Reference Guide for ESA therapy in Haemodialysis

Indication Haemoglobin consistently <105 g/L in an iron replete patient
Target Hb (g/l) Population target Hb range: 105 – 125 g/L. Hb should not be allowed to rise above 140g/L
Contraindications Uncontrolled hypertension (SBP >175mmHg, DBP >95mmHg)
Baseline Investigations (rationale)
  • Exclude occult blood loss
  • Reticulocyte count (to assess bone marrow responsiveness)
  • Iron studies (to ensure iron replete, i.e. Tsats >20%)
  • Vitamin B12 and Folate (to exclude nutritional deficiency)
  • PTH  (hyperparathyroidism can contribute to ESA resistance)
  • CRP (inflammation can contribute to ESA resistance)
  • TFTs (hypothyroidism can contribute to ESA resistance)
Initiation Dosing
The typical starting dose of Neorecoromon is 150 units/kg body weight/week. This is usually administered as 3 divided doses (but can be given as a single weekly dose), given intravenously during haemodialysis.
Monitoring Haemoglobin is checked monthly, although more frequent monitoring can be requested if clinically indicated.
Dose Adjustment (induction period) – If the rate of rise is <10 g/L/month, increase weekly ESA dose by 25%
– If the rate of rise of Hb is ≥ 15 g/l/month, decrease weekly dose by 25-50%
Dose Adjustment (stable period) – If Hb exceeds 125g/L, reduce weekly dose by 25-50% and consider period of discontinuation
– If Hb falls below 100g/l, increase weekly dose by 25%
Resistance If ESA doses ≥250units/kg/week are required to maintain haemoglobin, this should be discussed with senior staff and patients should be investigated for causes of ESA resistance.