Doctors should review how they diagnose and monitor anaemia in people with chronic kidney disease to reduce the risk of strokes and other health complications associated with high haemoglobin levels in certain individuals.

New evidence has prompted the National Institute for Health and Clinical Excellence (NICE) to update its recommendations on the levels of haemoglobin that help doctors determine when their patients with chronic kidney disease should receive treatment, as well as the safe haemoglobin limits that they should aspire to keep their patients within.

Chronic kidney disease (CKD) is an irreversible condition, strongly associated with high blood pressure and diabetes. Moderate to severe CKD may affect the ability of the kidneys to help make red blood cells, which carry oxygen around the body. Anaemia occurs when the quality or quantity of red blood cells are below normal. If untreated, anaemia can increase the risk of cardiovascular complications (e.g. left ventricular hypertrophy) and exacerbate symptoms (e.g. tiredness, lethargy, sleep disturbance and shortness of breath). This can lead to increased hospital visits, impaired quality of life and in some cases, death.

In 2006, NICE advised healthcare professionals to maintain the haemoglobin levels of their patients with CKD between 10.5 and 12.5 g/dl for adults, teenagers and children aged 2 and above, and between 10 and 12 g/dl for children under two years. Further studies have since been published which indicate that having haemoglobin levels above 12 g/dl doesn't bring any additional clinical benefit and may even possibly cause some health risks.

In response, NICE has updated these recommendations and is now advising healthcare professionals to maintain the haemoglobin range between 10 and 12g/dl for adults, teenagers and children over two years, and to between 9.5 and 11.5 g/dl for those under two years of age.

NICE is also urging doctors to not wait until their patients' haemoglobin levels are outside of these ranges before adjusting their treatments (e.g. they should act when their patient's haemoglobin levels are within 0.5 g/dl of the range's limit).

Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE said: "Anaemia in chronic kidney disease affects around 100,000 people nationally and can be very harmful. However, its side effects can be kept at bay if managed properly.

"We have partially updated our clinical guideline on the management of anaemia in chronic kidney disease because of recently published evidence relating to optimum target haemoglobin levels. It is important that healthcare professionals in renal units acknowledge the subtle but important changes that we have made to these recommendations as they carry some very serious safety concerns."

Other updated recommendations from NICE on the management of anaemia in CKD include:

--Consider investigating and managing anaemia in people with CKD if:

- Their haemoglobin (Hb) level falls to 11g/dl or less (or 10.5 g/dl[1]or less if younger than 2 years) or
- They develop symptoms attributable to anaemia, e.g. tiredness, shortness of breath, lethargy and palpitations.

-- When determining individual Hb ranges for people with anaemia in CKD, take into account patient preferences, symptoms and co-morbidities and the required treatment.

--Consider accepting Hb levels below the agreed aspirational range if:

- High doses of ESAs[2]are required to achieve the aspirational range, or
- The aspirational range is not achieved despite escalating ESA doses.

--Consider accepting Hb levels above the agreed aspirational range when:

- These develop with iron therapy alone or
- These develop with low doses of ESAs or
- It is thought that the person might benefit (e.g. if they have a physically demanding job) or
- The absolute risk of cerebrovascular disease is thought to be low.

Dr Paul Stevens, a Consultant Renal Physician and Clinical Adviser to the independent group that developed the updated guideline for NICE said: "It is well established that haemoglobin levels fall as a person's kidney function declines. When NICE originally published its clinical guideline on the management of anaemia, the available evidence at the time suggested that there was little clinical benefit in treating patients with chronic kidney disease for anaemia if their haemoglobin levels were above 12.5 g/dl.

"Since then studies have been published which suggest that striving to achieve higher haemoglobin levels increases the risks of health complications, such as stroke and thrombosis, with no additional benefit. The updated recommendations support the lower range highlighted in these studies, enabling clinicians to deliver the safest possible care for their patients."


About the clinical guideline

1. Read more about NICE's rapid update to its clinical guideline 114 on Anaemia management in chronic kidney disease.

2. NICE published its original clinical guideline on Anaemia management in chronic kidney disease in 2006. Since then, randomised controlled trials were published by CHOIR, CREATE and TREAT which have prompted NICE to update its existing recommendations regarding target haemoglobin levels.

3. This rapid update does not alter the scheduled review date for the clinical guideline in its entirety - it will still be considered for update later this year. For further information visit here.

[1] NICE previously advised healthcare professionals to consider investigating and managing anaemia in children under 2 years if their Hb levels fall to 10 g/dl.

[2] ESAs - Erythropoiesis Stimulating Agents are chemicals similar to a protein naturally secreted by the kidneys which help to make red blood cells.


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