Extent and Management of Extent and Management of Anaemia in Transplant PatientsAnaemia in Transplant Patients

EDTNA/ERCA EDTNA/ERCA Anaemia&Transplant Interest Anaemia&Transplant Interest

GroupsGroups

TRESAMTRESAM

38.6% anaemia during a 5 year post-38.6% anaemia during a 5 year post-transplant periodtransplant period

8.5% severe anaemia 8.5% severe anaemia Risk factors: renal function, ACEI/ARB, Risk factors: renal function, ACEI/ARB,

donor age, recent infection donor age, recent infection

only 18.5% pts with severe anaemia only 18.5% pts with severe anaemia treated with erythropoietintreated with erythropoietin

USA Yorgin et alUSA Yorgin et al (2002) (2002)

26% anaemic at 5 years post-transplant 26% anaemic at 5 years post-transplant Renal function greatest risk factorRenal function greatest risk factor 63% anaemic on switching from aza to 63% anaemic on switching from aza to

MMFMMF

““Anemia, which is a treatable complication, Anemia, which is a treatable complication, is significantly and independently associated is significantly and independently associated with mortality and graft failure in kidney-with mortality and graft failure in kidney-transplanted patients”transplanted patients”

Molnar et al 2007.AmJTranspl.7(4)Molnar et al 2007.AmJTranspl.7(4)

European Best Practice GuidelinesEuropean Best Practice Guidelines

Hb >11g/dL Hb >11g/dL

PTA is commonPTA is common Needs to be ManagedNeeds to be Managed Monitor and evaluate reasons for anaemiaMonitor and evaluate reasons for anaemia European Best Practice GuidelinesEuropean Best Practice Guidelines

The SurveyThe Survey

PostalPostal English for UK, Netherlands, Belgium, English for UK, Netherlands, Belgium,

Luxemburg; rest translatedLuxemburg; rest translated

Extent and management of PTAExtent and management of PTA

Questions askedQuestions asked What is the total number of dialysis patients in your centre?What is the total number of dialysis patients in your centre? Are transplants carried out at your centre?Are transplants carried out at your centre? How many transplant patients are followed up in your centre?How many transplant patients are followed up in your centre? How many of these transplant patients currently use Epo?How many of these transplant patients currently use Epo? Who monitors the full blood count in your transplant patients?Who monitors the full blood count in your transplant patients? Is there an identified person with sole responsibility for monitoring anaemia in Is there an identified person with sole responsibility for monitoring anaemia in

your transplant patients?your transplant patients? What percentage of your transplant patients have a haemoglobin < 11.0 g/dL?What percentage of your transplant patients have a haemoglobin < 11.0 g/dL? What parameters do you use to determine the cause of anaemia in your What parameters do you use to determine the cause of anaemia in your

transplant patients?transplant patients? Does your centre specify a haemoglobin below which a transplant patient is Does your centre specify a haemoglobin below which a transplant patient is

normally started on Epo?normally started on Epo? Do you have any specific algorithms / protocols to manage anaemia in your Do you have any specific algorithms / protocols to manage anaemia in your

transplant patients?transplant patients? What protocols do you have?What protocols do you have? Would you find it useful to have a comprehensive algorithm?Would you find it useful to have a comprehensive algorithm? Comments ?Comments ?

centres responding in each centres responding in each countrycountry

13 countries13 countries GermanyGermany 10 (26%) 10 (26%) SpainSpain 6 (15%) 6 (15%) GreeceGreece 4 (10%) 4 (10%) IsraelIsrael 4 (10%) 4 (10%) AustriaAustria 3 ( 8%) 3 ( 8%) UKUK 3 ( 8%) 3 ( 8%) BelgiumBelgium 2 ( 5%) 2 ( 5%) Bosnia-HerzegovinaBosnia-Herzegovina 2 ( 5%) 2 ( 5%) CroatiaCroatia 1 ( 3%) 1 ( 3%) HungaryHungary 1 ( 3%) 1 ( 3%) LuxemburgLuxemburg 1 ( 3%) 1 ( 3%) SerbiaSerbia 1 ( 3%) 1 ( 3%) SloveniaSlovenia 1 ( 3%)1 ( 3%) ______________________________________________________________

response rate = 32% (39/123)

number of dialysis patients per number of dialysis patients per centrecentre

No. of centres respondingNo. of centres responding 28 28

Mean (SD)Mean (SD) 196 (245) 196 (245)

MedianMedian 113 113

RangeRange 20-1130 20-1130

transplant activitytransplant activity________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________

Transplant Carried OutTransplant Carried Out YesYes 33 (85%) 33 (85%) NoNo 1 ( 3%) 1 ( 3%) No AnswerNo Answer 5 (13%) 5 (13%) Number of Transplant Patients FollowedUpNumber of Transplant Patients FollowedUp Number of centres responding Number of centres responding 38 38 Mean (SD)Mean (SD) 512 (512) 512 (512) MedianMedian 340 340 RangeRange 35->2000 35->2000 % Transplant Patients Using Epo% Transplant Patients Using Epo Number of centres responding Number of centres responding 28 28 Mean (SD) Mean (SD) 20 (16) 20 (16) Median Median 14 14 Range Range 2-712-71 ____________________________________________________________________________________ ____________________________________________________________________________________

monitoring blood count/anaemiamonitoring blood count/anaemia

______________________________________________________________________________________________________ Person Monitoring Blood Counts in Person Monitoring Blood Counts in Transplant Patients Transplant Patients ______________________________________________________________________________________________________ DoctorDoctor 37 (95%) 37 (95%) Transplant NurseTransplant Nurse 11 (28%) 11 (28%) Nephrology NurseNephrology Nurse 3 ( 8%) 3 ( 8%) OtherOther 3 ( 8%) 3 ( 8%) Identified Person Monitoring Anaemia 12 (31%) Identified Person Monitoring Anaemia 12 (31%)

percentage of transplant patients percentage of transplant patients with Hb <11 g/dlwith Hb <11 g/dl

__________________________________________________________________________________

Number of centres respondingNumber of centres responding 36 36 Mean (SD)Mean (SD) 16 (12) 16 (12) MedianMedian 15 15 RangeRange 2-602-60

_________________________________________ _________________________________________

parameters used to determine parameters used to determine cause of anaemiacause of anaemia

__________________________________________________________________________________ Parameter Parameter n (%) n (%) __________________________________________________________________________________ HbHb 38 (97%) 38 (97%) FerritinFerritin 33 (85%) 33 (85%) TransferrinTransferrin 25 (64%) 25 (64%) PTHPTH 25 (64%) 25 (64%) FolateFolate 24 (62%) 24 (62%) ReticulocytesReticulocytes 22 (56%) 22 (56%) Vitamin B12Vitamin B12 22 (56%) 22 (56%) Red Cell IndicesRed Cell Indices 18 (46%) 18 (46%) % Hypochromic Red Cells% Hypochromic Red Cells 14 (36%) 14 (36%) _________________________________________ _________________________________________

Hb threshold to start epoHb threshold to start epo__________________________________________________________________________________Hb (g/dl) Hb (g/dl) __________________________________________________________________________________ No threshold givenNo threshold given 10 10 8.08.0 1 ( 3%) 1 ( 3%) 9.09.0 2 ( 7%) 2 ( 7%) 10.010.0 9 (31%) 9 (31%) 10.510.5 7 (24%) 7 (24%) 11.011.0 7 (24%) 7 (24%) 11.511.5 2 ( 7%) 2 ( 7%) 12.012.0 1 ( 3%) 1 ( 3%) Mean (SD)Mean (SD) 10.4 (0.8)10.4 (0.8)MedianMedian 10.5 10.5 RangeRange 8.0-12.0 8.0-12.0 _________________________________________ _________________________________________

Hb threshold to start epoHb threshold to start epo

88.5

9

9.5

10

10.5 11

11.5

12

0

5

10

15

20

25

30

35

Hb level to start epo

%

Hb at which epo commencesHb at which epo commences

All questionnaires: range 8-12.0g/dLAll questionnaires: range 8-12.0g/dL

variation within countries- Germany variation within countries- Germany (most number of responses from single (most number of responses from single country): range 8-10.5g/dLcountry): range 8-10.5g/dL

13,347 pts covered by survey13,347 pts covered by survey 1,726 patients were anaemic (16%) 1,726 patients were anaemic (16%) PTA range 2-60%PTA range 2-60%

% anaemic transplant pts by % anaemic transplant pts by centrecentre

0

10

20

30

40

50

60

%

protocols for anaemia protocols for anaemia managementmanagement______________________________________________________________________________________________________________________

ParameterParameter n(%) n(%) ______________________________________________________________________________________________________________________ Use of EpoUse of Epo 29 (74%) 29 (74%) IV Iron AdministrationIV Iron Administration 27 (69%) 27 (69%) Immunosuppression ReviewImmunosuppression Review 25 (64%) 25 (64%) Modification of Other DrugsModification of Other Drugs 21 (54%) 21 (54%) Blood TransfusionBlood Transfusion 13 (33%) 13 (33%) FolateFolate 1 ( 3%) 1 ( 3%) Would Find Algorithm UsefulWould Find Algorithm Useful 30 (88%) 30 (88%) ______________________________________________________________________________________________________________________

% anaemia vs nurse or no nurse % anaemia vs nurse or no nurse monitormonitor

0

10

20

30

40

50

60

70

nurse no nurseRange 3-60%

Mean 20.8

Median 17.5

Range 2-40%

Mean 14.7

Median 12

%pts on epo vs %pts anaemic each %pts on epo vs %pts anaemic each centrecentre

0

10

20

30

40

50

60

epo

anaemia

%pts on epo vs %pts anaemic each %pts on epo vs %pts anaemic each centrecentre

0

10

20

30

40

50

60

0 10 20 30 40 50

% pts anaemic

%p

ts o

n e

po

%PTA vs epo threshold%PTA vs epo threshold

0

10

20

30

40

50

60

70

7 8 9 10 11 12 13 14

Hb below which start epo

% p

ts a

nae

mic

%anaemia vs use of algorithm%anaemia vs use of algorithm

0

10

20

30

40

50

60

70

-1 0 1 2

%p

ts a

nae

mic

mean 17.2%mean 15.8%

NO YES

summarysummary

Survey sent to 123 transplant centers in 13 Survey sent to 123 transplant centers in 13 countries. results show wide variance:countries. results show wide variance:

1,726 of 13,347 recipients were diagnosed as 1,726 of 13,347 recipients were diagnosed as being anaemic (average: 16%; range: 2-60%).being anaemic (average: 16%; range: 2-60%).

working protocols varied with respect to the working protocols varied with respect to the laboratory tests upon which anaemia was laboratory tests upon which anaemia was diagnosed, who monitored and/or treated diagnosed, who monitored and/or treated anaemia, Hb threshold for treatment, and anaemia, Hb threshold for treatment, and treatment.treatment.

Reticulocyecount

1 x for bloodloss/Haemolysis

Hb < 11 g/dl on 2 successive occasions

Investigate cause of Anaemia

AntiproliferativesmTOR inhibitors

ACEI/ARB

Refer to Doctor Assess Fe"status

eGFR Cockroft Gault/MDRD

< 30 ml/min GFREligible for EPOFollow A then B

Check B/P

< 125/80 mm Hg> 125/80 mm HgRefer to Dr for B/P

Doctor to set HbTarget & prescribe

EPO

Response

Maintenance Dose

Ferritin> 150 ng/dl

Check CRP

Check B12

Check red cell folate

Check PTH

Discuss with Dr

Ferritin< 200 ng/dl

Give IV iron

Reassess Fe "

status

Ferritin > 200 ng/dl+ Hb < 11 g/dl

Refer to Dr

Ferritin200 < ng/dl

Refer to Dr

Yes

No

+ ve

– ve

> 20

> 200

Normal

< 10 > 10

Low

<200

↑ (70x10 l)

B

A

Algorithm For Anaemia Management In Transplant Patients

Causes of PTACauses of PTA

ImmunosuppressantsImmunosuppressants InfectionInfection Antiviral drugsAntiviral drugs ACE-I, ARBsACE-I, ARBs Attitude!Attitude! CKD: funding, renal function, iron, folate, CKD: funding, renal function, iron, folate,

PTHPTH

conclusionconclusion

PTA is common: PTA is common: inadequate approach in inadequate approach in many centresmany centres

regular screening and evaluation of regular screening and evaluation of contributing factors is recommendedcontributing factors is recommended

EDTNA/ERCA pocket guide & algorithm, EDTNA/ERCA pocket guide & algorithm, slide setslide set

additional commentsadditional comments

- highlighted the need for dedicated person to - highlighted the need for dedicated person to monitor Hbmonitor Hb

-algorithm for Doctors not Nurses-algorithm for Doctors not Nurses

-epo only funded reliably for dialysis pts. Protocol -epo only funded reliably for dialysis pts. Protocol is for CRF ptsis for CRF pts

-tx centre not certified for epo use so nephrology -tx centre not certified for epo use so nephrology centre has to prescribe epo or ironcentre has to prescribe epo or iron

-protocol is for all patients. Useful to have alg. but -protocol is for all patients. Useful to have alg. but may not be followed by Drsmay not be followed by Drs

%pts on epo vs %pts anaemic each %pts on epo vs %pts anaemic each centrecentre

0

10

20

30

40

50

60

epo

anaemia

% anaemia vs nurse or no nurse % anaemia vs nurse or no nurse monitormonitor

0

10

20

30

40

50

60

70

1

%pts on epo vs %pts anaemic each %pts on epo vs %pts anaemic each centrecentre

0

10

20

30

40

50

60

70

0 5 10 15 20 25 30

%epo

%an

aem

ia

epo

anaemia

%pts on epo vs %pts anaemic each %pts on epo vs %pts anaemic each centrecentre

0

10

20

30

40

50

60

0 20 40 60 80

% pts anaemic

%p

ts o

n e

po

epo

Linear (epo)

%Hb<11 vs start epo Hb

0

10

20

30

40

50

60

70

8.0 9.0 10.0 11.0 12.0 13.0 14.0

0

5

10

15

20

25

30

35

40

45

7 8 9 10 11 12 13 14

Hb below which start epo

% p

ts a

nae

mic