What is the appropriate management for an 88-year-old patient with Chronic Kidney Disease (CKD) stage 3b, anemia, and impaired renal function, as indicated by a Glomerular Filtration Rate (GFR) of 37, hemoglobin of 126, and hematocrit of 0.37?

From the Guidelines

Management for this 88-year-old patient with CKD stage 3b should focus on slowing disease progression and monitoring for complications, though specific intervention for anemia is not currently needed, as the hemoglobin level of 126 g/L is above the threshold for initiating erythropoiesis-stimulating agents, which is typically considered when hemoglobin levels fall below 100 g/L 1. The patient should continue regular monitoring of kidney function with serum creatinine and GFR measurements every 3-6 months, along with electrolytes, calcium, phosphorus, parathyroid hormone, and vitamin D levels.

• Blood pressure should be controlled to a target of <130/80 mmHg using ACE inhibitors or ARBs as first-line agents, starting at low doses with careful monitoring for hyperkalemia or acute kidney injury.
• Dietary modifications include moderate protein restriction (0.8 g/kg/day), sodium restriction (<2.3 g/day), and potassium restriction if hyperkalemia develops. Despite the CKD diagnosis, the hemoglobin (126 g/L) and hematocrit (0.37) values are within normal range, so erythropoiesis-stimulating agents are not indicated at this time, but iron studies should be monitored, as iron is essential for hemoglobin formation and erythropoiesis requires both iron and erythropoietin 1. Additional management includes:
• Optimizing glycemic control if diabetic (HbA1c target 7-8%).
• Statin therapy for cardiovascular risk reduction.
• Avoiding nephrotoxic medications (NSAIDs, aminoglycosides).
• Adjusting medication dosages for reduced kidney function. Nephrology consultation is appropriate for this stage of CKD to establish a comprehensive management plan, especially considering the patient's age and potential for progression, as well as the need for close monitoring of kidney function and adjustment of treatment as necessary 1.

From the FDA Drug Label

For adult patients with CKD not on dialysis: Consider initiating Aranesp treatment only when the hemoglobin level is less than 10 g/dL and the following considerations apply:° The rate of hemoglobin decline indicates the likelihood of requiring a RBC transfusion and, ° Reducing the risk of alloimmunization and/or other RBC transfusion-related risks is a goal If the hemoglobin level exceeds 10 g/dL, reduce or interrupt the dose of Aranesp, and use the lowest dose of Aranesp sufficient to reduce the need for RBC transfusions.

The patient's hemoglobin level is 126 g/L, which is approximately 12.6 g/dL. According to the drug label, if the hemoglobin level exceeds 10 g/dL, the dose of Aranesp should be reduced or interrupted.

• Key considerations for this patient include:
  • The patient's hemoglobin level is above the target range
  • The patient has CKD stage 3b with a GFR of 37
  • The patient's hematocrit is 0.37 Given the patient's hemoglobin level is above 10 g/dL, no initiation of Aranesp treatment is recommended at this time 2.

From the Research

Patient Profile

• Age: 88 years
• CKD stage: 3b
• GFR: 37
• Hemoglobin: 126
• Hematocrit: 0.37

Anemia Management in CKD

The patient's anemia can be managed with erythropoiesis-stimulating agents (ESAs) as indicated by studies 3, 4, 5, 6, 7.

• ESAs, such as epoetin alfa and darbepoetin alfa, are commonly used to treat anemia in patients with CKD.
• The use of ESAs has been associated with improved quality of life, increased survival, and decreased progression of renal failure 3.
• However, correction of anemia to hemoglobin levels greater than 12 g/dL may increase the risk of adverse cardiac outcomes and progression of kidney disease in some patients 3.

ESA Hyporesponse

• Hyporesponse to ESAs is a common challenge in the management of anemia in CKD patients 4.
• The most common causes of ESA hyporesponse include iron deficiency and inflammation.
• Management of ESA hyporesponse involves treating underlying causes, ensuring adequate nutrition, and optimizing iron status and dialysis modality.

New Therapeutic Options

• New therapeutic options, such as HIF-PH inhibitors, have been developed to address ESA hyporesponse 4, 6.
• These agents have been shown to increase hemoglobin levels and reduce hepcidin levels, regardless of inflammation, iron status, or dialysis modality.

Treatment Considerations

• The choice of ESA and dosing regimen should be individualized based on the patient's response and tolerance 3, 7.
• The patient's iron status and hematocrit levels should be regularly monitored to adjust the ESA dose and prevent adverse effects.
• The potential risks and benefits of ESA therapy should be carefully considered, including the risk of cardiovascular events and hypertension 7.