2008 Japanese Society for Dialysis Therapy: Guidelines for Renal Anemia in Chronic Kidney Disease

Abstract

The Japanese Society for Dialysis Therapy (JSDT) guideline committee, chaired by Dr Y. Tsubakihara, presents the Japanese guidelines entitled "Guidelines for Renal Anemia in Chronic Kidney Disease." These guidelines replace the "2004 JSDT Guidelines for Renal Anemia in Chronic Hemodialysis Patients," and contain new, additional guidelines for peritoneal dialysis (PD), non-dialysis (ND), and pediatric chronic kidney disease (CKD) patients. Chapter 1 presents reference values for diagnosing anemia that are based on the most recent epidemiological data from the general Japanese population. In both men and women, hemoglobin (Hb) levels decrease along with an increase in age and the level for diagnosing anemia has been set at <13.5 g/dL in males and <11.5 g/dL in females. However, the guidelines explicitly state that the target Hb level in erythropoiesis stimulating agent (ESA) therapy is different to the anemia reference level. In addition, in defining renal anemia, the guidelines emphasize that the reduced production of erythropoietin (EPO) that is associated with renal disorders is the primary cause of renal anemia, and that renal anemia refers to a condition in which there is no increased production of EPO and serum EPO levels remain within the reference range for healthy individuals without anemia, irrespective of the glomerular filtration rate (GFR). In other words, renal anemia is clearly identified as an "endocrine disease." It is believed that defining renal anemia in this way will be extremely beneficial for ND patients exhibiting renal anemia despite having a high GFR. We have also emphasized that renal anemia may be treated not only with ESA therapy but also with appropriate iron supplementation and the improvement of anemia associated with chronic disease, which is associated with inflammation, and inadequate dialysis, another major cause of renal anemia. In Chapter 2, which discusses the target Hb levels in ESA therapy, the guidelines establish different target levels for hemodialysis (HD) patients than for PD and ND patients, for two reasons: (i) In Japanese HD patients, Hb levels following hemodialysis rise considerably above their previous levels because of ultrafiltration-induced hemoconcentration; and (ii) as noted in the 2004 guidelines, although 10 to 11 g/dL was optimal for long-term prognosis if the Hb level prior to the hemodialysis session in an HD patient had been established at the target level, it has been reported that, based on data accumulated on Japanese PD and ND patients, in patients without serious cardiovascular disease, higher levels have a cardiac or renal function protective effect, without any safety issues. Accordingly, the guidelines establish a target Hb level in PD and ND patients of 11 g/dL or more, and recommend 13 g/dL as the criterion for dose reduction/withdrawal. However, with the results of, for example, the CHOIR (Correction of Hemoglobin and Outcomes in Renal Insufficiency) study in mind, the guidelines establish an upper limit of 12 g/dL for patients with serious c...

International Comparisons to Assess Effects of Payment and Regulatory Changes in the United States on Anemia Practice in Patients on Hemodialysis: The Dialysis Outcomes and Practice Patterns Study

“…27 A 2008 update to the JSDT guidelines added 12 g/dl as a criterion for reducing or interrupting ESA treatment. 28 Although the distribution of lower Hb targets reported by Japanese DOPPS facilities has not changed much since 2010 ( Figure 3B), in recent years, we have observed a higher proportion of Japanese DOPPS facilities reporting upper Hb targets of 12 g/dl ( Figure 3A). In contrast, nonguideline position statements regarding anemia treatment in European patients with CKD released by the European Renal Best Practice (ERBP) group through 2010 generally suggested maintaining Hb levels between 11 and 12 g/dl.…”

Combination Therapy of Denosumab and Calcitriol for a Renal Transplant Recipient with Severe Bone Loss due to Therapy-Resistant Hyperparathyroidism

“…The current serum Cr level and eGFR are 2.6 mg/dL and 21.1 mL/min, respectively. On the other hand, in terms of the improvement of anemia, our patient could not maintain the optimum Hb level suggested by the guideline (Tsubakihara et al 2010) without blood transfusion, even after the resolution of SHPT.…”

Receipt of Intravenous Iron and Clinical Outcomes among Hemodialysis Patients Hospitalized for Infection

“…A strength of our study is that it evaluates outcomes among patients known to have active infection, which is the clinical scenario that closely aligns with the setting in which guidelines have recommended caution in prescribing (8,9), avoidance (1), and withholding (10) of intravenous iron. In addition, the sample size is larger than that of most studies examining the topic of intravenous iron and infection risk in hemodialysis patients (7).…”

“…The median LOS was 7 days (5-12), which was not significantly different between the groups that received (7 days [4][5][6][7][8][9][10][11]) and did not receive intravenous iron (7 days [5][6][7][8][9][10][11][12]; P=0.29). There were 3220 patients (14.1% of the cohort) who were readmitted for infection or died from any cause within 30 days of discharge.…”

“…Canadian and Japanese guidelines have advised caution and careful weighing of the risks and benefits of intravenous iron use in the setting of infection (8,9). Kidney Disease Improving Global Outcomes guidelines included a nongraded recommendation to avoid intravenous iron in patients with active systemic infections (1).…”