UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Treatment of anemia in peritoneal dialysis patients

Authors
Wajeh Y Qunibi, MD
William L Henrich, MD, MACP
Section Editor
Jeffrey S Berns, MD
Deputy Editor
Alice M Sheridan, MD

INTRODUCTION

Anemia is common among peritoneal dialysis patients and underlies many of the symptoms associated with reduced kidney function. Among such patients, untreated anemia is associated with increased mortality and an increased risk of hospitalization and hospital length of stay [1-4].

Screening for and treating anemia is a routine part of the care of peritoneal dialysis patients. This topic review provides an approach to screening and treating anemia. The treatment of iron deficiency among peritoneal dialysis patients is discussed elsewhere. (See "Treatment of iron deficiency in peritoneal dialysis patients".)

The screening and treatment of iron deficiency and anemia among nondialysis chronic kidney disease (CKD) patients and among hemodialysis patients are discussed elsewhere. (See "Treatment of anemia in nondialysis chronic kidney disease" and "Treatment of iron deficiency in nondialysis chronic kidney disease (CKD) patients" and "Treatment of iron deficiency in hemodialysis patients" and "Treatment of anemia in hemodialysis patients".)

DEFINITION

Anemia is defined by the World Health Organization (WHO) criteria as a hemoglobin (Hb) concentration <13 g/dL for adult males and postmenopausal women and an Hb <12 g/dL for premenopausal women [5]. (See "Approach to the adult patient with anemia", section on 'Normal ranges for hemoglobin/HCT'.)

However, the WHO definition of anemia does not define goals of treatment among peritoneal dialysis patients. This is because the goals of treatment of anemia with erythropoiesis-stimulating agents (ESAs) are to prevent the development of severe anemia and reduce the need for blood transfusions but not to normalize Hb levels. This approach is based on findings from several randomized, controlled trials among patients with chronic kidney disease and who are on hemodialysis showing that targeting a normal Hb with ESAs results in adverse outcomes. Studies have not been conducted in peritoneal dialysis patients. Regardless, the same principles likely apply to such patients. Thus, even when treated to accepted goals, peritoneal dialysis patients will have anemia as defined above.

                 

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Mon Nov 21 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Ma JZ, Ebben J, Xia H, Collins AJ. Hematocrit level and associated mortality in hemodialysis patients. J Am Soc Nephrol 1999; 10:610.
  2. Xia H, Ebben J, Ma JZ, Collins AJ. Hematocrit levels and hospitalization risks in hemodialysis patients. J Am Soc Nephrol 1999; 10:1309.
  3. Collins AJ, Li S, St Peter W, et al. Death, hospitalization, and economic associations among incident hemodialysis patients with hematocrit values of 36 to 39%. J Am Soc Nephrol 2001; 12:2465.
  4. Collins AJ, Ma JZ, Ebben J. Impact of hematocrit on morbidity and mortality. Semin Nephrol 2000; 20:345.
  5. World Health Organization. Nutritional Anaemias: Report of a WHO Scientific Group. Geneva, Switzerland: World Health Organization, 1968.
  6. Rastogi A, McDougall IC, Nissenson AR. Anemia in PD patients. In: Nolph and Gokal's Textbook of Peritoneal Dialysis, 3rd ed., Khanna R, Krediet RT. (Eds), Springer, New York 2009. p.713.
  7. United States Renal Data System. 2015 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 2015.
  8. Wetmore JB, Peng Y, Monda KL, et al. Trends in anemia management practices in patients receiving hemodialysis and peritoneal dialysis: a retrospective cohort analysis. Am J Nephrol 2015; 41:354.
  9. Lacson E Jr, Diaz-Buxo JA. The treatment of anemia in peritoneal dialysis patients. Clin Nephrol 2001; 56:415.
  10. Muirhead N. Erythropoietic agents in peritoneal dialysis. Perit Dial Int 2005; 25:547.
  11. Webb L, Gilg J, Wilkie M. Chapter 8 Haemoglobin, ferritin and erythropoietin amongst UK adult dialysis patients in 2010: national and centre-specific analyses. Nephron Clin Pract 2012; 120 Suppl 1:c145.
  12. Stankovic-Popovic V, Nesic V, Popovic D, et al. Effects of conventional versus biocompatible peritoneal dialysis solutions on peritoneal and systemic inflammation, malnutrition and atherosclerosis in CAPD patients. Clin Nephrol 2011; 76:314.
  13. Adachi Y, Nakagawa Y, Nishio A. In patients treated with peritoneal dialysis, icodextrin improves erythropoietin-resistant anemia through blockade of asialo receptors on hepatocytes. Adv Perit Dial 2006; 22:41.
  14. Wazny LD, Stojimirovic BB, Heidenheim P, Blake PG. Factors influencing erythropoietin compliance in peritoneal dialysis patients. Am J Kidney Dis 2002; 40:623.
  15. http://www.kdigo.org/clinical_practice_guidelines/pdf/KDIGO-Anemia%20GL.pdf.
  16. Chapter 1: Diagnosis and evaluation of anemia in CKD. Kidney Int Suppl (2011) 2012; 2:288.
  17. http://www.fda.gov/Drugs/DrugSafety/ucm259639.htm (Accessed on July 28, 2011).
  18. NKF-DOQI clinical practice guidelines for the treatment of anemia of chronic renal failure. National Kidney Foundation-Dialysis Outcomes Quality Initiative. Am J Kidney Dis 1997; 30:S192.
  19. IV. NKF-K/DOQI Clinical Practice Guidelines for Anemia of Chronic Kidney Disease: update 2000. Am J Kidney Dis 2001; 37:S182.
  20. NKF-K/DOQI Clinical Practice Guidelines for Anemia of Chronic Kidney Disease. Am J Kidney Dis 2006; 47(Suppl 4):S1.
  21. KDOQI. KDOQI Clinical Practice Guideline and Clinical Practice Recommendations for anemia in chronic kidney disease: 2007 update of hemoglobin target. Am J Kidney Dis 2007; 50:471.
  22. Kaufman JS, Reda DJ, Fye CL, et al. Subcutaneous compared with intravenous epoetin in patients receiving hemodialysis. Department of Veterans Affairs Cooperative Study Group on Erythropoietin in Hemodialysis Patients. N Engl J Med 1998; 339:578.
  23. Wright DG, Wright EC, Narva AS, et al. Association of Erythropoietin Dose and Route of Administration with Clinical Outcomes for Patients on Hemodialysis in the United States. Clin J Am Soc Nephrol 2015; 10:1822.
  24. Provenzano R, Garcia-Mayol L, Suchinda P, et al. Once-weekly epoetin alfa for treating the anemia of chronic kidney disease. Clin Nephrol 2004; 61:392.
  25. Piccoli A, Malagoli A, Komninos G, Pastori G. Subcutaneous epoetin-alpha every one, two, and three weeks in renal anemia. J Nephrol 2002; 15:565.
  26. Provenzano R, Bhaduri S, Singh AK, PROMPT Study Group. Extended epoetin alfa dosing as maintenance treatment for the anemia of chronic kidney disease: the PROMPT study. Clin Nephrol 2005; 64:113.
  27. Benz R, Schmidt R, Kelly K, Wolfson M. Epoetin alfa once every 2 weeks is effective for initiation of treatment of anemia of chronic kidney disease. Clin J Am Soc Nephrol 2007; 2:215.
  28. McGowan T, Vaccaro NM, Beaver JS, et al. Pharmacokinetic and pharmacodynamic profiles of extended dosing of epoetin alfa in anemic patients who have chronic kidney disease and are not on dialysis. Clin J Am Soc Nephrol 2008; 3:1006.
  29. Pergola PE, Gartenberg G, Fu M, et al. A randomized controlled study comparing once-weekly to every-2-week and every-4-week dosing of epoetin alfa in CKD patients with anemia. Clin J Am Soc Nephrol 2010; 5:598.
  30. Feriani M, De Meester JM, McMahon LP, et al. Extended dosing of darbepoetin alfa in peritoneal dialysis patients. BMC Nephrol 2011; 12:13.
  31. González MT, Ramos R, Vera M, et al. Monthly CERA treatment maintains stable hemoglobin levels in routine clinical practice of peritoneal dialysis patients. Ren Fail 2013; 35:314.
  32. Mahajan S, Boulton H, Gokal R. A trial of subcutaneous administration of darbepoetin alfa once every other week for the treatment of anemia in peritoneal dialysis patients. J Nephrol 2004; 17:687.
  33. Fang YW, Chang CH. Subcutaneous administration of darbepoetin alfa effectively maintains hemoglobin concentrations at extended dose intervals in peritoneal dialysis patients. Perit Dial Int 2009; 29:199.
  34. Jadoul M, Vanrenterghem Y, Foret M, et al. Darbepoetin alfa administered once monthly maintains haemoglobin levels in stable dialysis patients. Nephrol Dial Transplant 2004; 19:898.
  35. Ling B, Walczyk M, Agarwal A, et al. Darbepoetin alfa administered once monthly maintains hemoglobin concentrations in patients with chronic kidney disease. Clin Nephrol 2005; 63:327.
  36. Trachsler J, Glück Z, Dickenmann M, et al. Parameters for successful monthly extended dosing of darbepoetin-alpha in patients undergoing hemodialysis. Clin Nephrol 2009; 71:697.
  37. Theodoridis M, Passadakis P, Kriki P, et al. Efficient monthly subcutaneous administration of darbepoetin in stable CAPD patients. Perit Dial Int 2005; 25:564.
  38. Weiner DE, Miskulin DC, Seefeld K, et al. Reducing versus discontinuing erythropoietin at high hemoglobin levels. J Am Soc Nephrol 2007; 18:3184.
  39. Besarab A, Bolton WK, Browne JK, et al. The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoetin. N Engl J Med 1998; 339:584.
  40. Singh AK, Szczech L, Tang KL, et al. Correction of anemia with epoetin alfa in chronic kidney disease. N Engl J Med 2006; 355:2085.
  41. Churchill DN, Muirhead N, Goldstein M, et al. Probability of thrombosis of vascular access among hemodialysis patients treated with recombinant human erythropoietin. J Am Soc Nephrol 1994; 4:1809.
  42. Drüeke TB, Locatelli F, Clyne N, et al. Normalization of hemoglobin level in patients with chronic kidney disease and anemia. N Engl J Med 2006; 355:2071.
  43. Berns JS, Rudnick MR, Cohen RM, et al. Effects of normal hematocrit on ambulatory blood pressure in epoetin-treated hemodialysis patients with cardiac disease. Kidney Int 1999; 56:253.