Treating anaemia in people with chronic kidney disease

Treating anaemia in people with chronic kidney disease

If you are diagnosed with anaemia, you may be offered treatment with iron, or an erythropoiesis‑stimulating agent (often called an ESA), or both, depending on the cause of the anaemia. Iron can be used to treat anaemia if you have low levels of iron (called iron deficiency). ESAs can also be used to treat anaemia because they work like natural erythropoietin (EPO for short) to encourage the body to make more red blood cells. Low EPO levels are the main cause of anaemia in people with chronic kidney disease.

Treatment with iron

If you need treatment with iron, your anaemia specialist should discuss with you how this will be done and offer you iron tablets or iron infusions (iron injections given using a drip or in a single injection). The amount of iron you are taking should be checked to make sure you are not storing too much iron. Too much iron can be bad for your liver. If you are going to try taking an ESA to treat the anaemia (see treatment with ESAs), the iron deficiency should be treated before or at the same time you start ESA treatment.

If you are not taking ESAs

If you have low iron levels and you are not taking ESAs, you should be offered treatment with iron. Your anaemia specialist should discuss with you the risks and benefits of the different treatment options. If you are not having haemodialysis (or kidney dialysis – a procedure to remove fluid and waste products from the blood), you might be able to try taking iron tablets for a trial period to treat your low iron levels, rather than having iron infusions. If this works, you may not need to have iron infusions. But if taking iron tablets is causing you problems you should be offered iron infusions.

If you are having haemodialysis, you should be offered iron infusions. But if iron infusions wouldn't be suitable for you, or you choose not to have them, you should be offered iron tablets.

Your doctor should discuss the results of the iron treatment with you (and your family or carers, if appropriate) and offer you ESA therapy if they think it would benefit you (see 'treatment with ESAs'). But if the iron treatment has been successful you may not need to have ESA therapy.

If you are taking ESAs

Adults and young people

If you are aged 14 years or over, you are already taking ESAs (see 'treatment with ESAs') and your iron levels become too low, your anaemia specialist should discuss with you the risks and benefits of possible treatments for this. You should be offered iron infusions. But if you choose not to have iron infusions, or iron infusions wouldn't be suitable for you, you should be offered iron tablets instead.

Children

If you are aged 13 years or younger, you are taking ESAs (see 'treatment with ESAs') and having haemodialysis, your anaemia specialist should discuss treating your iron deficiency with you (and your family or carers, if appropriate) and the risks and benefits of the different treatment options. You should be offered iron infusions.

If you are taking ESAs but you are not having haemodialysis, you may be offered iron tablets rather than iron infusions. But if you have problems taking the iron in tablet form, or your haemoglobin levels are still too low after 3 months, you should be offered iron infusions.

If you are having haemodialysis at home

If you are having haemodialysis at home, and you are offered iron infusions, you may need to have the iron infusions in a centre that has the medical facilities you might need if you became very unwell.

Off‑label use of iron infusions

At the time of publication iron infusions may be recommended for 'off-label' use for children and young people in this guideline. Your doctor should tell you this and explain what it means for you.

Continuing with iron

Once your iron levels are okay, your anaemia specialist should discuss whether or not you need to keep taking the iron. But if you are taking an ESA, you will need to continue taking iron, either in tablet form or as an infusion. Your anaemia specialist should explain the iron levels that you are aiming for. (See tests for checking if your anaemia treatment is working.)

Treatment with ESAs

One of the ways of treating anaemia in people with chronic kidney disease is by ESA injections, although you will usually hear the injections referred to as EPO injections.

You should be offered an ESA if it is likely to benefit you (some people's medical problems mean they wouldn't receive any benefit from ESA treatment). The decision about whether to offer you an ESA should be based on whether the treatment would be suitable for you, regardless of your age.

There are different ESAs available, and your anaemia specialist should try to find the one that will suit you best. They should explain the differences between the ESAs, and discuss whether you want to inject them yourself or have a healthcare professional to help. You should also discuss how often this should be done, how you're likely to cope with the injections, how to store ESAs at your home and the different ways they are supplied (for example, whether you collect them from your hospital or whether they are delivered to your home). This should be agreed with you and recorded in a care plan, and the plan should be reviewed if your needs or preferences change. If you are taking an ESA it is important that your blood pressure is checked regularly (see the box below on information and support).

If it's uncertain whether you would benefit from taking an ESA, you should be able to try taking one for a trial period, if you want to, to find out how it might help you. Your anaemia specialist should discuss with you (and your carers, if appropriate) the pros and cons of having ESA treatment for a trial period.

The box below gives details of the information you should have if you're considering ESA treatment.

Information and support you should have if you're thinking about having ESA treatment

  • Information on why ESA treatment is needed, how it works, and the possible benefits and side effects (your GP should also have this information).

  • Information about why it is important to take the ESAs as directed.

  • Arrangements should be made so that you can obtain your ESA supply as easily as possible if you are going to inject it yourself.

Continuing with ESAs

Your anaemia specialist should check and discuss with you how the ESA treatment is going, and whether you should continue with the same ESA or change to a different one. It may be necessary to adjust your dose and how often you have an injection to keep your haemoglobin levels stable. Haemoglobin is needed to transport oxygen around the body in red blood cells. If your haemoglobin level changes unexpectedly, you should be offered tests to find the reason for this so that it can be treated. (See checking whether your treatment is working.)

If you are having ESA treatment for a trial period you, your family (or carers) and your anaemia specialist should discuss how the trial went and agree whether to continue or stop the ESA treatment.

Questions to ask about treatment

  • Can you tell me why you have decided to offer me this particular type of treatment?

  • What are the pros and cons of having the treatment you've recommended?

  • Please tell me about what the treatment involves.

  • How will the treatment help me? What effect will it have on my symptoms and everyday life? What sort of improvements might I expect?

  • How long will it take to have an effect?

  • Will I always need this treatment?

  • Are there risks or side effects associated with this treatment?

  • What if I don't want the treatment? What are my options other than the recommended treatment?

  • Is there some written information about the treatment I could have?

  • How will I feel after the treatment?

  • Will the treatment hurt?

  • How often will I need to have the treatment?

  • Can I take something from my chemist or health food shop?

  • Can I talk to other patients about my treatment options?

Hyperparathyroidism

If you have increased levels of a hormone called parathyroid hormone (known as hyperparathyroidism, which is usually a result of the kidneys not working well), your anaemia specialist should think about whether treating it would help your anaemia, and discuss this with you.

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