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Content Update

Jan. 14, 2019

New Evidence Supports Use of High-Dose IV Iron to Treat Anemia in Patients Undergoing Maintenance Hemodialysis: A randomized controlled trial of high-dose vs. low-dose IV iron sucrose in adults with end-stage renal disease on maintenance hemodialysis found that high-dose iron was noninferior to low-dose iron with respect to the primary composite outcomes of myocardial infarction, nonfatal stroke, hospitalization for heart failure, or death from any cause. The median monthly iron dose was 264 mg in the high-dose group and 145 mg in the low-dose group. The cumulative dose of erythropoiesis-stimulating agents (ESAs) was 19.4% lower in the high-dose group. Patients who received high-dose iron required fewer blood transfusions and lower ESA doses to maintain target Hb concentrations, indicating an ESA dose-sparing effect. Although these results are promising, further study is needed to determine optimal iron dosing, generalizability to other iron formulations, and long-term effects of high-dose iron.

LEARNING OBJECTIVES

LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. List the risk factors that increase susceptibility for chronic kidney disease (CKD).

  2. Explain the mechanisms associated with progression of CKD.

  3. Outline the desired outcomes for treatment of CKD.

  4. Develop a therapeutic approach to slow progression of CKD including lifestyle modifications and pharmacologic therapies.

  5. Identify specific consequences associated with CKD.

  6. Design an appropriate therapeutic approach for specific consequences associated with CKD.

  7. Recommend an appropriate monitoring plan to assess the effectiveness of pharmacotherapy for CKD and specific consequences.

  8. Educate patients with CKD about the disease state, the specific consequences, lifestyle modifications, and pharmacologic therapies used for treatment of CKD.

INTRODUCTION

The kidney is made up of approximately 2 million nephrons that are responsible for filtering, reabsorbing, and excreting solutes and water. The kidney has three primary functions: excretory (excrete fluid, electrolytes, and solutes); metabolic (metabolize vitamin D and some drugs, such as insulin and some beta-lactams); and endocrine (produce erythropoietin [EPO]). As the number of functioning nephrons declines, the primary functions of the kidney that are affected include:

  • Production and secretion of EPO

  • Activation of vitamin D

  • Regulation of fluid and electrolyte balance

  • Regulation of acid–base balance

Chronic kidney disease (CKD) is defined as abnormalities in the structure or function of the kidney, present for 3 months or more, with implications for health.1 Markers of structural abnormalities include albuminuria (30 mg/24 hours or more or an albumin:creatinine ratio [ACR] of more than 30 mg/g [or 3.5 mg/mmol for female and 2.5 mg/mmol for male, but varies between different guidelines and location]); hematuria or casts in urine sediment; electrolyte and other abnormalities caused by renal tubular disorders; abnormalities detected by histology or imaging; or history of kidney transplantation. Functional abnormalities are indicated by a decline in glomerular filtration rate (GFR) less than 60 mL/min/1.73m2 (0.58 mL/s/m2). Generally, CKD is a progressive decline in kidney function (number of ...

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