Early management of renal anaemia in predialysis patients and its impact on their left ventricular hypertrophy, progression of renal failure and quality of life

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ACKNOWLEDGEMENT

I would take this opportunity to thank my research supervisor, family and friends for their support and guidance without which this research would not have been possible.

DECLARATION

I [type your full first names and surname here], declare that the contents of this dissertation/thesis represent my own unaided work, and that the dissertation/thesis has not previously been submitted for academic examination towards any qualification. Furthermore, it represents my own opinions and not necessarily those of the University.

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Table of Contents

ACKNOWLEDGEMENTII

DECLARATIONIII

CHAPTER 2: LITERATURE REVIEW1

Identification and Treatment3

Iron Management8

Clinical Effectiveness11

Cost Effectiveness14

Management of acute renal failure15

Management of chronic renal failure16

Optimizing the use of recombinant human erythropoietin18

Iron Supplementation20

The effectiveness of different strategies to use iron supplementation23

Convenience and Cost Effectiveness26

REFERENCES28

CHAPTER 2: LITERATURE REVIEW

This review aims to examine the evidence for the efficacy and effectiveness of iron therapy in the early management and treatment of anaemia of CKD patients who have not yet started dialysis therapy (predialysis patients) in relation to Safety Clinical, effectiveness, Quality of life and Cost effectiveness, as iron therapy is recognised as an integral component of any anaemia management strategy and is high cost in term of delivery and time being mainly based in secondary care in hospitals. This review will examine current literature on the subject and it is hoped that it may be possible to assimilate and consolidate the available evidence and present it in a form that is suitable to inform the evidence base on the subject, also to ensure best practice is adhered to and followed on our ward. It also aims to present a comprehensive thematic analysis of the major publications, and will thus enable me to educate junior doctors, medical students visiting the ward and non-physicians (nurses, patients and their relatives) in the management of one of the most important consequences of advanced chronic kidney disease.

Most patients with end-stage renal disease (ESRD) develop anemia and require therapy with erythropoietin (EPO) and parenteral iron to maintain a target hematocrit (Hct) of 33% to 36% and a target hemoglobin (Hgb) of 11 to 12 g/dl. Recent clinical practice guidelines from the National Kidney Foundation Dialysis Outcomes Quality Initiative (NKFDOQI)[ 1] suggest that adequate iron stores and biologic availability are necessary for optimal Hct and Hgb control. These guidelines suggest methods of providing iron replacement in iron-deficient patients and provide recommendations for maintenance dosing of iron for patients on continued EPO therapy who are iron replete.

Iron dextran and sodium ferric gluconate complex in sucrose (hereafter referred to as "iron gluconate") are the only parenteral iron agents currently available in the United States. Iron dextran has been available for a number of years and is marketed as two products, INFeD and DexFerrum. Although they are not chemically identical, they have a similar clinical profile. Iron gluconate was approved by the FDA in February 1999 and is marketed as Ferrlecit. (DOH, 2005).

Identification and Treatment

Anaemia is a common complication ...