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Badura K, Janc J, Wąsik J, Gnitecki S, Skwira S, Młynarska E, Rysz J, Franczyk B. Anemia of Chronic Kidney Disease-A Narrative Review of Its Pathophysiology, Diagnosis, and Management. Biomedicines 2024; 12:1191. [PMID: 38927397 PMCID: PMC11200696 DOI: 10.3390/biomedicines12061191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/28/2024] Open
Abstract
Anemia is one of the most common chronic kidney disease (CKD) complications. It negatively affects patients' quality of life and clinical outcomes. The pathophysiology of anemia in CKD involves the interplay of various factors such as erythropoietin (EPO) deficiency, iron dysregulation, chronic inflammation, bone marrow dysfunction, and nutritional deficiencies. Despite recent advances in understanding this condition, anemia still remains a serious clinical challenge in population of patients with CKD. Several guidelines have been published with the aim to systematize the diagnostic approach and treatment of anemia; however, due to emerging data, many recommendations vary between publications. Recent studies indicate a potential of novel biomarkers to evaluate anemia and related conditions such as iron deficiency, which is often present in CKD patients. Our article aims to summarize the pathophysiology of anemia in CKD, as well as the diagnosis and management of this condition, including novel therapeutic approaches such as hypoxia-inducible factor-prolyl hydroxylase inhibitors (HIF-PHI). Understanding these complex subjects is crucial for a targeted approach to diagnose and treat patients with anemia in CKD effectively.
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Affiliation(s)
- Krzysztof Badura
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Jędrzej Janc
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Joanna Wąsik
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Szymon Gnitecki
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Sylwia Skwira
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Ewelina Młynarska
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Beata Franczyk
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
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The Association between Iron Deficiency and Renal Outcomes Is Modified by Sex and Anemia in Patients with Chronic Kidney Disease Stage 1–4. J Pers Med 2023; 13:jpm13030521. [PMID: 36983703 PMCID: PMC10057396 DOI: 10.3390/jpm13030521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/11/2023] [Accepted: 03/12/2023] [Indexed: 03/17/2023] Open
Abstract
Iron deficiency is prevalent in women and patients with chronic kidney disease (CKD). Iron deficiency is not only related to anemia but contributes to adverse consequences for the kidney as well. Whether iron status is associated with renal outcomes after considering sex and anemia in patients with CKD stage 1–4 is unclear. Thus, we investigated the association of iron or iron saturation with renal outcomes in a CKD cohort. During a follow-up of 8.2 years, 781 (31.2%) patients met the composite renal outcome of renal replacement therapy and a 50% decline in renal function. In linear regression, iron was associated with sex, hemoglobin (Hb), and nutritional markers. In a fully adjusted Cox regression model, the male patients with normal iron had a significantly decreased risk of renal outcomes (hazard ratio (HR) 0.718; 95% confidence interval (CI) 0.579 to 0.889), but the female patients did not exhibit this association. The non-anemic patients (Hb ≥ 11 g/dL) had a decreased risk of renal outcomes (HR 0.715; 95% CI 0.568 to 0.898), but the anemic patients did not. In the sensitivity analysis, transferrin saturation (TSAT) showed similar results. When comparing iron and TSAT, both indicators showed similar prognostic values. In conclusion, iron deficiency, indicated by either iron or iron saturation, was associated with poor renal outcomes in the male or non-anemic patients with CKD stage 1–4.
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Reticulocyte Hemoglobin-Equivalent Potentially Detects, Diagnoses and Discriminates between Stages of Iron Deficiency with High Sensitivity and Specificity. J Clin Med 2022; 11:jcm11195675. [PMID: 36233545 PMCID: PMC9572493 DOI: 10.3390/jcm11195675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/18/2022] [Accepted: 09/21/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Iron deficiency anemia (IDA) is a global health problem affecting the quality of life of more than 2 billion individuals. The current practice guidelines diagnose and monitor IDA via conventional hematological and iron biomarkers, which take several months before they are corrected under an iron-treatment plan. Reticulocyte hemoglobin equivalent (Ret-He) is used as a marker in most new hematology analyzers to assess iron incorporation into erythrocyte hemoglobin directly. This study aims to examine the efficacy of Ret-He as a marker for iron deficiency (ID) and IDA and investigate whether Ret-He is sensitive to iron therapy. Methods: Two blood samples were drawn from 182 participants for CBC and iron profile measurements. Follow-up samples were drawn from participants with a confirmed diagnosis of ID and/or IDA. Results: Ret-He levels were lower in the ID and IDA groups compared to the control (p < 0.0001), and lower in the IDA group compared to the ID group (p < 0.0001). Ret-He was correlated with ferritin at ID level (<30.0 mg/mL; r = 0.39) and severe IDA (<13.0 ng/mL; p-value < 0.01, r = 0.57). Cut-off values of <28.25 pg for ID and <21.55 pg for IDA showed a higher specificity and sensitivity (ID; AUC: 0.99, sensitivity: 92.73%, specificity: 97.87%) and (IDA; AUC: 0.94, sensitivity: 90.63%, specificity: 92.31%). Finally, Ret-He successfully reflected the iron therapy (p < 0.001) when compared to hemoglobin (Hb) (p = 0.1). Conclusions: Ret-He is a potential marker for detecting and diagnosing different stages of ID with high validity and is very sensitive in reflecting the iron incorporation in a short time.
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Bone Marrow Hypocellularity in Patients with End-Stage Kidney Disease. Healthcare (Basel) 2021; 9:healthcare9111452. [PMID: 34828498 PMCID: PMC8621268 DOI: 10.3390/healthcare9111452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/12/2021] [Accepted: 10/22/2021] [Indexed: 11/17/2022] Open
Abstract
Background. Anemia and pancytopenia are not uncommon in patients with chronic kidney disease (CKD). Nevertheless, there is insufficient literature analyzing bone marrow pathology in patients with CKD or end-stage kidney disease (ESKD) receiving dialysis. Methods. This observational cohort study included 22 patients with ESKD and 23 patients with CKD that received bone marrow biopsy and aspiration at Chang Gung Memorial Hospital. Demographic, hematological, and biochemical data were collected at the time of bone marrow study for analysis. Results. Bone marrow aspiration demonstrated that patients with ESKD had a lower percentage of blasts than patients with CKD (0.52 ± 0.84 versus 1.06 ± 0.78 %, p = 0.033). Bone marrow biopsy revealed that the overall incidence of hypocellular bone marrow was 55.6%. Furthermore, patients with ESKD had higher proportion of hypocellular bone marrow than patients with CKD (72.7% versus 39.1%, p = 0.023). In a multivariate logistic regression model, it was revealed that ESKD status (odds ratio 9.43, 95% confidence interval 1.66–53.63, p = 0.011) and megakaryocyte count within bone marrow (odds ratio 0.48, 95% confidence interval 0.29–0.79, p = 0.004) were significant predictors for bone marrow hypocellularity. Conclusion. Bone marrow hypocellularity is common in patients with kidney dysfunction. Hypocellular marrow occurs more frequently in patients with ESKD than patients with CKD.
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Freeland-Graves JH, Sachdev PK, Binderberger AZ, Sosanya ME. Global diversity of dietary intakes and standards for zinc, iron, and copper. J Trace Elem Med Biol 2020; 61:126515. [PMID: 32450495 DOI: 10.1016/j.jtemb.2020.126515] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/19/2020] [Accepted: 03/30/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The essentiality of trace elements in human diets is well recognized and adequate levels are a critical component of optimal health. To date, public health efforts have focused primarily on macronutrients or trace minerals that are easily analyzed. The goal of this research is to provide assessment of the dietary standards developed for Zn, Fe, and Cu in 100+ developed, marginal, and developing countries. We summarize the current recommendations and changes from the last decade, categorize and provide scientific basis for values established, factors that affect requirements, and current global challenges. METHODS The electronic databases of Google Scholar, PubMed, Embase, Web of Science and Cochrane Library were searched using the keywords "trace minerals," "micronutrients, ""zinc," "iron," "copper," "dietary standards" and "recommendations." A total of 123 studies published from 1965 to 2019 were included. RESULTS The World Health Organization (WHO) has established dietary standards to address nutrient deficiencies, prevent infections and ensure basic metabolic functions; these are utilized by most developing countries. Developed countries or their alliances have established values similar to or higher than the WHO, primarily for promotion of optimal health and well-being. Transitional countries are more concerned with issues of bioavailability, food security and undernutrition. Globally, Zn and Cu recommendations are lower in women than in men; Fe requirements are higher to compensate for menstrual losses. Important considerations in establishing guidelines for these minerals include bioaccessibility, dietary practices and restrictions, food processing, interactions, and chemical forms. The global challenges of the triple burden of malnutrition, hidden hunger, increased consumption of ultra-processed foods and obesity have been associated with Zn, Fe, and Cu deficiencies. CONCLUSION This research provides public policy and health professionals evidenced-based information useful for the establishment of dietary standards world-wide.
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Affiliation(s)
- Jeanne H Freeland-Graves
- T.S Painter Hall 5.20, The University of Texas at Austin, Department of Nutritional Sciences, College of Natural Sciences, 103 W 24TH ST A2703, Austin, TX, 78712, United States.
| | - Prageet K Sachdev
- T.S Painter Hall 3.18, The University of Texas at Austin, Department of Nutritional Sciences, College of Natural Sciences, 103W 24th St A2703, Austin, TX, 78712, United States.
| | - Annemarie Zamora Binderberger
- T.S Painter Hall 3.18, The University of Texas at Austin, Department of Nutritional Sciences, College of Natural Sciences, 103W 24th St A2703, Austin, TX, 78712, United States.
| | - Mercy Eloho Sosanya
- T.S Painter Hall 3.18, The University of Texas at Austin, Department of Nutritional Sciences, College of Natural Sciences, 103W 24th St A2703, Austin, TX, 78712, United States.
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Batchelor EK, Kapitsinou P, Pergola PE, Kovesdy CP, Jalal DI. Iron Deficiency in Chronic Kidney Disease: Updates on Pathophysiology, Diagnosis, and Treatment. J Am Soc Nephrol 2020; 31:456-468. [PMID: 32041774 PMCID: PMC7062209 DOI: 10.1681/asn.2019020213] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Anemia is a complication that affects a majority of individuals with advanced CKD. Although relative deficiency of erythropoietin production is the major driver of anemia in CKD, iron deficiency stands out among the mechanisms contributing to the impaired erythropoiesis in the setting of reduced kidney function. Iron deficiency plays a significant role in anemia in CKD. This may be due to a true paucity of iron stores (absolute iron deficiency) or a relative (functional) deficiency which prevents the use of available iron stores. Several risk factors contribute to absolute and functional iron deficiency in CKD, including blood losses, impaired iron absorption, and chronic inflammation. The traditional biomarkers used for the diagnosis of iron-deficiency anemia (IDA) in patients with CKD have limitations, leading to persistent challenges in the detection and monitoring of IDA in these patients. Here, we review the pathophysiology and available diagnostic tests for IDA in CKD, we discuss the literature that has informed the current practice guidelines for the treatment of IDA in CKD, and we summarize the available oral and intravenous (IV) iron formulations for the treatment of IDA in CKD. Two important issues are addressed, including the potential risks of a more liberal approach to iron supplementation as well as the potential risks and benefits of IV versus oral iron supplementation in patients with CKD.
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Affiliation(s)
| | - Pinelopi Kapitsinou
- Feinberg Cardiovascular and Renal Research Institute and
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Pablo E Pergola
- Renal Associates PA, Division of Nephrology, University of Texas Health Science Center at San Antonio, San Antonio, Texas; and
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Diana I Jalal
- Division of Nephrology, University of Iowa Hospitals and Clinics, Iowa City, Iowa;
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Haupt L, Weyers R. Determination of functional iron deficiency status in haemodialysis patients in central South Africa. Int J Lab Hematol 2016; 38:352-9. [PMID: 27136325 DOI: 10.1111/ijlh.12492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 03/08/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Functional iron deficiency (FID) is characterized by adequate body iron stores with an inadequate rate of iron delivery for erythropoiesis. In chronic kidney failure (CKD), iron availability is best assessed using the percentage of hypochromic red cells (%Hypo). The aim of our study was to determine the FID status of haemodialysis patients in central South Africa, using the %Hypo analyte and to evaluate the ability of the currently used biochemical tests, transferrin saturation (TSat) and serum ferritin to diagnose FID. METHODS For this study, 49 patients on haemodialysis were recruited. Haemoglobin (Hb), mean cell volume (MCV) and %Hypo were measured on the Advia 2120i. Biochemical analytes (serum ferritin, TSat) and C-reactive protein (CRP) levels were also recorded. RESULTS Of the 49 participants, 21 (42.9%) were diagnosed with FID (%Hypo >6%). A large number of patients (91.8%) were anaemic. The TSat demonstrated poor sensitivity and specificity for diagnosing FID compared with %Hypo. The use of %Hypo (rather than TSat) to guide intravenous iron use spared 16 patients the potential harmful effects thereof. CONCLUSION Using %Hypo as a single analyte to diagnose FID will lead to more appropriate use of limited resources and a reduction in treatment-related complications.
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Affiliation(s)
- L Haupt
- Faculty of Health Sciences, Department of Haematology and Cell Biology, University of the Free State, Bloemfontein, South Africa
| | - R Weyers
- Faculty of Health Sciences, Department of Haematology and Cell Biology, University of the Free State, Bloemfontein, South Africa
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ESA and iron therapy in chronic kidney disease: a balance between patient safety and hemoglobin target. Kidney Int 2014; 86:676-8. [DOI: 10.1038/ki.2014.179] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Hung SC, Lin YP, Tarng DC. Erythropoiesis-stimulating agents in chronic kidney disease: what have we learned in 25 years? J Formos Med Assoc 2013; 113:3-10. [PMID: 24090633 DOI: 10.1016/j.jfma.2013.09.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 08/22/2013] [Accepted: 09/02/2013] [Indexed: 10/26/2022] Open
Abstract
Since the pioneering studies by Eschbach et al in 1987, erythropoiesis-stimulating agents (ESAs) have become the mainstay of anemia therapy in chronic kidney disease (CKD) patients. The introduction of ESAs 25 years ago markedly improved the lives of many patients with CKD, who until then had severe, often transfusion-dependent anemia. However, randomized controlled trials demonstrate an increased risk for cardiovascular events such as stroke, thrombosis, and death at nearly normal hemoglobin concentrations and higher ESA doses in CKD. By contrast, kidney transplant recipients may represent a unique population of CKD patients who may benefit from ESA therapy. This review discusses potential mechanisms involving the erythropoietic and nonerythropoietic effects of ESA treatment and ESA resistance. Further research aimed at elucidating the causal pathways is strongly recommended. Given current knowledge, however, clinical practice should avoid disproportionately high dosages of ESAs to achieve recommended hemoglobin targets, particularly in those with significant cardiovascular morbidity or ESA resistance. The key to CKD anemia management will be individualization of the potential benefits of reducing blood transfusions and anemia-related symptoms against the risks of harm.
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Affiliation(s)
- Szu-Chun Hung
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Buddhist Tzu Chi University, Taipei, Taiwan
| | - Yao-Ping Lin
- Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Der-Cherng Tarng
- Division of Nephrology, Department of Medicine, and Immunology Research Center, Taipei Veterans General Hospital, Taipei, Taiwan; Department and Institute of Physiology, National Yang-Ming University, Taipei, Taiwan.
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