BP control

Currently, there is insufficient evidence to support a SBP goal <130 mmHg in CKD with urine protein-to-creatinine ratio <0.22. In patients with CKD and proteinuria that is >1 g/d, a SBP of 120–130 mmHg isrecommended.

Anemia of CKD is defined as a Hb (hemoglobin) <12 g/dL (female) or <13.5 g/dL (male), with adequate iron availability by parameters: TSAT (transferrin saturation) >20% and ferritin >100 ng/mL.In CKD Stage 5, the ferritin target is >200 ng/mL.

2007 UPDATE OF HEMOGLOBIN TARGET states aClinical Practice Recommendation for a Hb target of 11.0 to 12.0 g/dL and a top-level Hb of 13.0 g/dL in CKD.

Therapeutic Targets

• Hb 10–12 g/dL† (do not exceed Hb 13 g/dL)
• TSAT >20% but <50%
• Ferritin >100 ng/mL‡
• CHr >32 pg/cell*

†Therapeutic phlebotomy should not be undertaken, if the Hb is 13–18 g/dL, in the absence of ESA therapy, unless symptoms are present, eg, headache.‡Ferritin >800 ng/mL is not a contraindication to the use oral or parenteral iron; interpretation ofclinical context and trend analysis of iron utilization is required, particularly with inflammation.*CHr (mean cellular hemoglobin content of reticulocytes); utility of this parameter has only beenvalidated in hemodialysis-dependent ESRD patients.

**Erythropoiesis-Stimulating Agents (ESAs)**Epoetin alfa (Procrit® or Epogen®): 10–40,000 Units, subcutaneously, q1–4 wk;begin therapy at Hb <10 g/dL at starting dose, 100 Units/kg/wk.Darbepoetin alfa (Aranesp®): 40–300 mcg, subcutaneously, q2–4 wk or q1 mo;begin therapy at Hb <10 g/dL at starting dose, 0.9 mcg/kg/q2 wk (equivalent to package insertdose, 0.45 mcg/kg/wk)NB: ESA therapy entails informed consent at each administration. In hemodialysis patients,administration of vitamin D may reduce ESA utilization.

COMMENTS• Ascorbic acid (vitamin C) should be co-administered with iron in achlorhydric patients(250 mg per iron tablet), during H2 antagonist or PPI therapy, or after gastric ulcer surgery (eg,Billroth II surgery).• Ca-based P-binders bind iron salts.• Consult a nephrologist before initiating ESA treatment, if oral iron therapy does not achieveHb 10 g/dL or if parenteral iron is considered.• Dose conversion ratio of epoetin alfa to darbepoetin alfa is ~225–260 to 1.• EPO levels should not be measured as part of a routine anemia evaluation.• ESAs are contraindicated during acute blood loss.• Iron salts should only be ingested on an empty stomach.• Iron salts bind fluoroquinolones, tetracyclines, Ca-based P-binders, and levothyroxine.Administer thyroid hormones separately from iron.• Parenteral iron is contraindicated during active infection.

Roxadustat (Evrenzo) is a hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI) used to treat symptomatic anemia associated with chronic kidney disease (CKD) in both dialysis and non-dialysis patients. It increases hemoglobin levels and improves iron regulation, taken orally 3 times a week.