Conservative Kidney Management

Anemia Guideline

Guiding Principles

Patients with CKD are at risk of anemia which can contribute to fatigue and breathlessness. Common management strategies include the use of erythropoiesis stimulating agents and iron supplementation. Bloodwork related to anemia is typically done monthly for chronic kidney disease patients; this could be decreased to every 3 months for conservatively managed patients but should be based on patient preference and symptoms.

GFR 15 - 5 | Slow Decline/Deteriorating | Last 0-5 years of life

For CKM patients, anemia is treated with the goal of decreasing fatigue and dyspnea, as opposed to reducing cardiac mortality or morbidity.

Interventions should be continued only for so long as they are of symptomatic benefit. It should be explained to patients and caregivers early on that there may come a time when the interventions no longer benefit the patient, at which time they would be stopped.

See: Fatigue Guideline
See: Breathlessness Guideline

GFR 5 - 0 | Intensive/Near Death | Last 0-2 months of life

As the patient nears the end of life, it is no longer appropriate to manage fatigue and dyspnea via these interventions and they should be stopped. Providing supportive care to address fatigue and using medications such as opioids to manage dyspnea are appropriate interventions at this time.

See: Fatigue Guideline
See: End of Life Breathlessness Algorithm

Objectives

To achieve adequate hemoglobin and iron levels in kidney failure patients who have true iron deficiency and anemia resulting from their kidney disease.
Note that interventional guidelines do not replace individualized care and clinical expertise.

Iron Protocol for Conservatively Managed Patients

TSAT (Transferrin Saturation) 20% to 49%

This is considered iron-replete; maintain iron stores.

TSAT (Transferrin Saturation) less than 20%

If patient’s iron stores are low and if patient is not already on oral iron supplement, contact most responsible healthcare provider to consider low dose therapy.
If receiving oral iron, increase to next incremental tolerated dose (see below).
An IV iron regime may be considered if the patient is unable to tolerate or reach target levels with oral iron (see below).

Intermittent IV iron infusion – Adults Venofer (iron sucrose)

Administer usual concentrations up to 2 mg/mL (mixed in Normal Saline) but higher concentrations may be used.
Infuse over the following time periods:
- 200mg or less; at least 15 minutes
- 300mg; at least 90 minutes
- 400mg; at least 150 minutes
- 500mg; at least 210 minutes

Drug	Elemental Iron/Tablet	Dose Adjustment Increment (increase or decrease by)	Maximum dose
Note: Oral iron may cause constipation
*Proferrin consists of a blood product (heme iron peptide) made from animal haemoglobin and should NOT be taken if allergic to meat products of if animal or blood-based products are not allowed in the diet (i.e., vegan, Jehovah Witness)
(adapted from AHS Anemia Management Guideline (June 2017), Alberta Kidney Care (AKC) - CKD, PD, HD Programs)
Polysaccharide Iron Complex	150 mg/150 mg	150 mg tablet	300 mg/day
Ferrous Sulfate	60 mg/300 mg	300 mg tablet	900 mg/day
Ferrous Fumerate	100 mg/300 mg	300 mg tablet	600 mg/day
Ferrous Fumerate (liquid)	100 mg/5 mL	5 mL	10 mL/day
Ferrous Gluconate	35 mg/300 mg	300 mg tablet	900 mg/day
Proferrin*	11 mg/11 mg	11 mg tablet	33 mg/day