Care of the Chronic Kidney Disease Patient

Ruth C. Campbell, MD, and Jeffrey S. Berns, MD. (Andrew Z. Fenves, MD, FASN, moderator, and Daniel C. Batlle, MD, discussant)
(ASN Renal Week Official Symposium, November, 2008.)
Campbell: What is a systems approach to management of anemia in a CKD clinic? Where are the bottlenecks and how does one get through them? What is the role of point-of-service Hb testing? Scheduling of patient appointments? Insurance and drug assistance programs? What are protocols that take into account extended dosing intervals? What are useful iron protocols? How can we help make our CKD protocols concordant with recent FDA package insert warnings? Berns: Which outcomes are of clinical importance that Hb adjustment may improve? What did CHOIR and CREATE show, and how did the secondary analysis of CHOIR suggest that EPO dose per se may be a risk factor? What did the FDA alerts say? How does ESA therapy impact on cost of care for CKD patients before starting dialysis? What are the potential benefits of individualized patient management? (more...)




Shades of Grey: Key Questions in the Future of Treatment for CKD-Related Anemia

Rebecca J. Schmidt, DO, FASN; Robert D. Toto, MD; Keith C. Norris, MD, FASN
(ASN Renal Week Official Symposium, November, 2008.)
Schmidt: What are current estimates of CKD in the US population and the projected changes in the nephrology workforce? What are opportunities for improving care, re Hb levels, AV access, dietitian consultation? What are the results of a multidisciplinary approach to CKD? What constitutes the multidisciplinary team and what are their roles?
Toto: How do observational and randomized trials differ in terms of benefits of more complete anemia correction? Specifically, what did each type of trial show in terms of CV endpoints, LV mass index, and quality of life? What is the TREAT study and how will it add to our knowledge in this area?
Norris: How might the FDA black box warnings re ESAs pertaining to cancer and deep vein thrombosis impact CKD patients? How does the KDOQI 2007 anemia update differ from the FDA black box warnings? (more...)




The ESA Controversy: The Role of Intravenous Iron

Tomas Ganz, MD, PhD; Rajiv Agarwal, MD, MBBS, FASN; Anatole Besarab, MD, FACP (moderated by Adeera Levin, MD)
(ASN Renal Week Official Symposium, November, 2008.)
Ganz: What are the 3 means by which hepcidin levels are regulated? What is ferroportin and where does it act? What are physiologic and pathologic conditions in which hepcidin is either high or low?
Agarwal: What is the rationale for routine iron maintenance therapy as opposed to a load-and-hold strategy? What were results of studies targeting higher TSAT and/or allowing higher serum ferritin levels? What are potential advantages of adding iron to the dialysate? How much iron do dialysis patients need in a typical year?
Besarab: What are the most recent FDA guidelines re ESA use? What does recent reanalysis of the CHOIR trial suggest regarding the importance of ESA dose and adverse outcomes? What is the basis of the time lag in Hb response after changes in ESA dose? How can one minimize Hb variability? What effect does IV iron therapy have on ESA requirements? (more...)


Van Buskirk  


Stabilizing Hemoglobin Levels: What's New in IV Iron and Anemia Management?

Steven Fishbane, MD; Suzann VanBuskirk, BSN, RN, CNN; Kristin Larson, RN, ANP, BNP, CNN
(ANNA National Symposium, Philadelphia, PA. April, 2008.) 1.5 CNE
VanBuskirk: How common is Hb variability in ESRD patients, and how does this correlate to outcomes? What are its possible causes? How do iron and ESA impact on red blood cell production? At what stage of erythropoiesis does each act? What is the role of hepcidin? What are the factors controlling reponse to ESA therapy? How can IV iron be used to optimize response to ESA and minimize Hb variability? Fishbane: What is the recent guidance from KDOQI, CMS, and the FDA regarding ESA therapy? What were the risks of using higher ESA dosing to target higher Hb levels identified in the normal Hct trial, the CHOIR trial, and the CREATE trial? What did the mandated black box warning say? What approach did the FDA recommend to ESA hyporesponsive patients? What should be the ESA strategy in light of the new recommendations? What does KDOQI recommend in terms of IV iron usage? Regarding serum ferritin? What did the DRIVE study show regarding using IV iron in patients with higher serum ferritin levels? Larson: How can we learn from case studies how to minimize Hb variability? What are the potential risks of higher ESA doses? How can we individual treatment with both IV iron and ESA to help maintain a stable Hb level? (more...)





Achieving Control: Optimizing the Management of CKD-Anemia

Allen R. Nissenson, MD; Steven Fishbane, MD; Michael J. Germain, MD; Robert Provenzano, MD
(CME Symposium (Synermed-Penn State), March, 2008.)
Nissenson: What is the difference between target and achieved hemoglobin? What did the 2007 KDOQI anemia update recommend and what were the results of the KDOQI meta-analysis? Fishbane: In CKD, at what point should one start to treat a low Hb? What is the approach to ESA hyporesponsiveness? How can one dose iron and ESA in such a way to limit Hb variability? Why is Hb variability relevant? Germain: What are the various drugs available to stimulate red cell production? What are their pharmacokinetics? To what extent is pharmacologic half-life associated with the time course of Hb response, especially with less frequent dosing? Is Hb variability different with shorter and longer half-life drugs? How frequently should Hb be monitored? What are good strategies for ESA dosing adjustment? Provenzano: What are areas were care of predialysis CKD patients might be improved? What resources do such patients utilize? What is the cost of providing care to them? What is the opportunity for providing care to this population and maintain reimbursement to have a viable practice? What is the RPA CKD management toolkit, and how can it help in the care of these patients? What are services, revenue, and costs of a CKD clinic model? (more...)

Updated: December 14, 2015 (Dec14)
Dec14 Even more news on the new HDCN Facebook page!
Jul16 ISHD to sponsor 2-day Hemodialysis University in Chicago on August 15/16, 2014.
Dec14 Long-term use of proton-pump inhibitors linked to vitamin B12 deficiency.
Mar20 Vel-negative blood type and transfusion risk now better understood.
Mar17 Macrophages found to play key role in regulating red blood cell levels.
Mar17 Darbepoietin treatment does not improve survival in anemic heart failure patients.
Feb24 Fatal allergic reactions to Omontys (peginesatide) trigger recall.
Dec26 Blood transfusion associated with increased risk of heart attack.
Nov10 Loss of essential blood gene (Atpif1) leads to anemia.
Nov01 DOPPS practice monitor updated in October 2012
Sep03 Protein found to regulate red blood cell size and number.
Aug16 DOPPS Practice Monitor website
Aug02 KDIGO releases new, 2012 version of anemia guidelines; 9.0 g/dL Hb is the new lower bound.
Jul18 Trial of EPO pump underway.
Jul12 Affymax inks deal to supply Omontys (peginesatide) to Fresenius in the U.S.
Industry Advances Emphasis
Shades of Grey: Key Questions in the Future of Treatment for CKD-Related Anemia (Toto, Schmidt) ASN Renal Week 2008
Care of the Chronic Kidney Disease Patient (Campbell, Berns) ASN Renal Week 2008
The ESA Controversy: The Role of Intravenous Iron (Ganz, Agarwal, Besarab) ASN Renal Week 2008
Managing the Anemia Patient: Financial Considerations Today and in the Future (Singh) ADC 2008
How Do We Achieve an Optimal Hemoglobin Target:  The EPO-Iron Balance (Coyne) ADC 2008
Predictors of IV Iron Responsiveness: Serum Ferritin - Should We Measure It at All? (Singh) ADC 2008
Red cell survival in relationship to changes in the hematocrit: more important than you think (Uehlinger) RRI 2008
Blind Pugh sends a black spot: The current hemoglobin controversy (E. Stevens) RRI 2008
New Developments in Anemia Management in Chronic Kidney Disease (Roy, Besarab, Amerling) ASN Renal Week 2007
Navigating the Erythropoietin Stimulating Agent Landscape in CKD-Related Anemia (Berns, Provenzano, Szczech) ASN Renal Week 2007
EPO Therapy: What's Old, What's Coming? (Besarab) ADC 2007
Pharmaco-Economics: What Should Be Our Concern? (Wish) ADC 2007
What Are the Implications of NKF/KDOQI Anemia Guidelines and Clinical Practice Recommendations (Folkert) ADC 2007
Predictors of Response in EPO Resistant Patients (Shapiro) ADC 2007
New Frontiers in Iron Deficient Anemia (W. Coyne) ADC 2007
Debate: The New K/DOQI Guidelines Provide Safe and Adequate Standards (M. Bargman) RRI 2007
Debate: The 2006 K/DOQI Guidelines for Peritoneal Dialysis Adequacy Are Not Adequate (Winchester) RRI 2007
What should the target Hgb Level be? (Fishbane) RRI 2007
Impact of the Change in CMS Billing Rules for Erythropoietin on Hemoglobin Outcomes in Dialysis Patients (J. Ofsthun) RRI 2007
Vit C Neglect in HD: Sailing Between Scylla and Charybdis (Handelman) RRI 2007
Evidence-Based Anemia Management (target: nurses) (McCarley) ANNA 2006
A Balanced Approach to Anemia Therapy: IV Iron and EPO (target: nurses) (Easom, Bowe) ANNA 2006
The New KDOQI Guidelines for Anemia, a Debate: Should the Upper Hgb Limit be 12 or 13 g/dL? ASN Renal Week 2006
A New Tri-Partite Approach to Anemia ASN Renal Week 2006
Anemia Management in CKD: Improving Anemia Management (target: nurses) (Reed, Copeland) ANNA 2006
Practical Considerations for the Management of Anemia in Nephrology Patients: Searching for an Improved Erythropoietic Treatment (Pereira, Wish, Aronoff) ANNA 2006
Practical Considerations for the Management of Anemia in Nephrology Patients: Searching for an Improved Erythropoietic Treatment. RPA Satellite Symposium, 2006
Anemia in the PD Patient (Michael V. Rocco, MD, MS, FACP; Allen R. Nissenson, MD, FACP; Chaim Charytan, MD; David B. Van Wyck, MD) ADC 2006 (audio only)
New Developments in Anemia and Erythropoietin Science (Ganz, Lin, Singh) ASN Renal Week 2005 (audio only)
Anemia in Renal Disease: Update and Case Discussion (Berns, Van Wyck) ASN Renal Week 2005
The Role of Iron Deficiency in Anemia Management: Key Controversies (Wish, Zager, Kalantar-Zadeh, Agarwal) ASN Renal Week 2005
Anemia and Iron Management: Addressing Challenges and Generating Solutions (target: nurses) (Easom, Volkert) ANNA 2005
Complications of Anemia and the CKD Patient (target: nurses) (Petroff) ANNA 2005
Treating Patients With IV Iron Therapy: Special Considerations (target: nurses) (Fishbane, Warady) ANNA 2005
Maximizing Patient Outcomes Through IV Iron Therapy and Appropriate Iron Measures (Agarwal, Coyne) RRI Sat 2005

Arterial hypertension induced by erythropoietin and erythropoiesis-stimulating agents (ESA) Clin J Am Soc Nephrol (Feb 2009)
Location of acute coronary artery thromboses in patients with and without chronic kidney disease Kidney Int (Jan 2009)
Secondary analysis of the CHOIR trial epoetin-alpha dose and achieved hemoglobin outcomes Kidney Int (Sep 2008)
Should patients with venous thromboembolism be screened for thrombophilia? Am J Med (Jun 2008)
High-molecular weight iron dextran: a wolf in sheep's clothing? J Am Soc Nephrol (May 2008)
Technology insight: biomarker development in acute kidney injury-what can we anticipate? Nature Clin Pract Nephrol (Mar 2008)
The optimal hemoglobin in dialysis patients -- a critical review Semin Dial (Feb 2008)
Mechanisms of disease: erythropoietin resistance in patients with both heart and kidney failure Nature Clin Pract Nephrol (Jan 2008)
Mechanism of increased mortality risk with erythropoietin treatment to higher hemoglobin targets (Fishbane et al) Clin J Amer Soc Nephrol (Nov 2007)
Management of hyperkalemia in dialysis patients (Putcha et al) Semin Dial (Oct 2007)
Latest U.S. KDOQI anaemia guidelines update-what are the implications for Europe? (MacDougall et al) Nephrol Dial Transplant (Oct 2007)
Nonhematological benefits of iron (Agarwal) Am J Nephrol (Oct 2007)
Recombinant EPO production-points the nephrologist should know (Jelkmann) Nephrol Dial Transplant (Oct 2007)
The target hemoglobin level in patients on dialysis (Singh AJ) Dial Transplant (Jul 2007)
Anemia of CKD - the CHOIR study revisited (Singh et al) Nephrol Dial Transplant (Jul 2007)
Weighing the hazards of erythropoiesis stimulation in patients with cancer (Khuri) N Engl J Med (Jun 2007)
Weighing the Hazards of Erythropoiesis Stimulation in Patients with Cancer (FR Khuri) N Engl J Med (Jun 2007)
Clinical aspects of iron use in the anemia of kidney disease JASN 02-07
Clinical aspects of iron use in the anemia of kidney disease (Hoerl) JASN (02-2007)
Understanding recent haemoglobin trials in CKD: methods and lesson learned from CREATE and CHOIR NDT (02-07)
(2006 Pharma )Year in Review (Michele B. Kaufman, PharmD, RPh) Dial-Transplant 12-06
2007 Update
Topic Pages
Anemia / Iron Rx
Prescribing info
Epogen (Amgen)
EPO (Procrit)

Dr. Steve Fishbane
Associate Professor of Medicine, Associate Chairman, Department of Medicine, Winthop-University Hospital, Mineola, NY