Introduction

Anaemia is defined as a state in which the quality or quantity of circulating red blood cells is below normal. Blood haemoglobin (Hb) concentration serves as the key indicator for anaemia because it can be measured directly and has an international standard. A major cause of anaemia of chronic kidney disease (CKD) is a reduction in erythropoietin production due to kidney damage. Erythropoietin stimulates the bone marrow to produce red blood cells, and it is produced by the kidney in response to low tissue oxygen levels.

Possible adverse effects of anaemia include reduced oxygen use, increased cardiac output, left ventricular hypertrophy, reduced cognition and concentration, reduced libido and reduced immune responsiveness.

The guideline development group for this 2015 update considered the evidence in several areas that provide challenges for clinicians managing anaemia of CKD. Recombinant human erythropoietin (also called EPO, an erythropoietic stimulating agent or ESA) for treating anaemia of CKD is an important tool in managing the condition. But some CKD patients with anaemia who are offered an ESA are 'ESA resistant' – that is, their condition consistently fails to respond to the ESA treatment. These patients often receive large doses of ESA, sometimes with blood transfusion, with limited benefits and at significant cost to the NHS. Many CKD patients with anaemia receiving an ESA are admitted with an intercurrent illness – such as pneumonia – which may temporarily render them acutely hyporesponsive to that ESA. There is uncertainty about the management of these groups of patients, and these areas were considered in the update. The update once again highlighted the often limited trial evidence in nephrology, compared with other specialities.

Over the past decade attention has shifted to the role and management of iron deficiency in anaemia of CKD. In CKD patients there is often a complex inflammatory state that makes it difficult to diagnose iron deficiency when using its standard markers, such as serum iron, serum total iron binding capacity or ferritin. In recent years evidence has been published on newer markers of iron deficiency and intravenous iron preparations. In this 2015 update, the guideline development group reassessed the diagnosis and management of iron deficiency in CKD, and made several recommendations in these areas.

This guideline covers the management of anaemia in adults, children and young people with a clinical diagnosis of anaemia associated with CKD. It does not cover people with anaemia not principally caused by CKD. All parts of the care pathway are covered in the guideline.

There is no universally accepted classification for categorising the population with anaemia of CKD by age. However, for the purposes of this guideline the Guideline Development Group agreed on a pragmatic classification based on the licensing of iron preparations in different age groups. The age groups defined in this guideline are as follows:

  • children: 0–13 years

  • young people: 14–17 years

  • adults: 18 years and over.

Safeguarding children

Remember that child maltreatment:

  • is common

  • can present anywhere

  • may co‑exist with other health problems, including anaemia of chronic kidney disease.

See the NICE guideline on child maltreatment for clinical features that may be associated with maltreatment.

Medicines

The guideline will assume that prescribers will use a medicine's summary of product characteristics to inform decisions made with individual patients.

This guideline recommends some medicines for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or those with authority to give consent on their behalf) should provide informed consent, which should be documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. Where recommendations have been made for the use of medicines outside their licensed indications ('off‑label use'), these medicines are marked with a footnote in the recommendations.

  • National Institute for Health and Care Excellence (NICE)