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The purpose of this analysis was to quantify haemoglobin (Hb) variability in patients receiving haemodialysis (HD) and erythropoiesis-stimulating agent (ESA) treatment from data independently collected in two different geographical settings. STUDY DESIGN, SETTINGS AND PATIENTS: Two studies retrospectively reviewed patients undergoing HD and stable ESA treatment at centres in Australia and the UK (56 and 154 patients, respectively). Monthly Hb values were obtained over a 12-month period. The frequency, duration, amplitude and direction of Hb fluctuations (Hb outside the range 11-12 g/dl in the Australian data-set and 11-12.5 g/dl in the UK data-set) were evaluated.The overall mean Hb level was 11.27 and 11.71 g/dl in the Australian and UK data-set, respectively. All patients experiencedor =1 Hb fluctuation and 68-73% hador =3 fluctuations over the study period. Upward and downward Hb fluctuations occurred with similar frequency and were of similar amplitude. Fluctuations of more extreme amplitude (high amplitude fluctuations) were more common than fluctuations of lesser amplitude. The total duration of time spent outside the Hb range (mean +/- standard deviation) was 8.6 +/- 2.5 and 7.4 +/- 2.5 months in the Australian and UK data-set, respectively. The total duration with Hb11 g/dl was 3.7 +/- 3.0 and 3.7 +/- 2.7 months, respectively. Most patients (95%) required ESA dose adjustment; the median number of dose adjustments per patient was 2 (range 0-5).Despite the study limitations of retrospectivity and its cross-sectional nature, the reported observations that Hb fluctuations outside target ranges occur frequently in patients on HD receiving ESAs are clearly confirmed and were strikingly similar in the two different geographical locations.

BACKGROUND Management of anemia is an important factor in the care of patients with chronic kidney disease as the anemic state can confer significant morbidity and mortality. Posttransplantation anemia (PTA) has received comparatively less attention in the literature, and the prevalence and predictors of PTA vary between different studies. The purpose of this study was to investigate a large posttransplant population from 3 centres in the UK to elucidate the point prevalence of PTA, its determinants and the use of erythropoiesis stimulating agents (ESA) in these patients. METHODS All adult patients with functioning renal transplants and attending renal transplant outpatients at Guy's, King's College, or St. Helier Hospitals, London, as of 31/12/2004 who had a valid hemoglobin in the previous 3 months, and who were more than 3 months postengraftment, were identified. Patients' notes and electronic patient records were obtained and a detailed cross-sectional clinical and biochemical database was constructed. The data were analyzed for the point prevalence of PTA, the prevalence of ESA use and for determinants of hemoglobin. The WHO criteria were used to define anemia and all patients on treatment with an ESA was classified as anemic irrespective of hemoglobin. RESULTS A total of 1,511 (947 male) patients were studied. Mean age was 48.1+/-13.7 years with no difference between the sexes. Mean time posttransplantation was 8.5+/-7.2 years and mean estimated MDRD GFR was 47.6+/-18.9 ml/min with a higher GFR in males (49.9+/-19.0 v 43.8+/-18.0 mL/min, P

Background: Intravenous iron supplementation is an integral part of the management of anemia in patients with chronic kidney disease. Traditionally, this has been administered as an infusion over 1 or more hours, which requires the use of intravenous fluids and administration tubing, along with extra demands on patient and nursing time. Methods: We prospectively investigated the safety and practicality of administering iron sucrose, 200 mg, as a bolus injection over 2 minutes in patients with chronic kidney disease. A total of 2,297 injections were administered to 657 patients. Any adverse events were recorded, including acute anaphylactoid reactions to the iron injection, along with the presence or absence of metallic taste and phlebitis, and these were classified as "serious" and "nonserious." Results: The most common adverse event was a mild and transient metallic taste that occurred during 412 injections (17.9%); in no case was this of significant distress to the patient. Excluding this, 2,240 injections (97.5%) proceeded uneventfully, and no case of phlebitis was recorded. Adverse events other than metallic taste were recorded in association with 57 injections (2.5%). Seven of these were caused by an acute anaphylactoid reaction to the intravenous iron. All 7 acute reactions resolved completely within 30 minutes with no sequelae, and none required hospitalization. The remaining 50 adverse events consisted of pain during the injection (n = 31), pain after the injection with or without some bruising (n = 9), nausea/gastrointestinal symptoms (n = 3), lethargy (n = 4), and lightheadedness (n = 3). Conclusion: Administration of 200 mg of iron sucrose as an intravenous bolus injection over 2 minutes is a practical dosing regimen in patients with chronic kidney disease, resulting in considerable savings in time and cost.

Most, if not all, nephrologists are aware of the explosion of epoetin-associated cases of pure red cell aplasia, particularly in Europe, from 1998 onwards [1–4]. The dramatic increase in reported cases was largely associated with a particular brand of epoetin alfa (Eprex; Erypo) [5], but a few cases have also been reported with epoetin beta [3]. Epoetin-associated pure red cell aplasia is characterized by a sudden loss of response to the drug, with the haemoglobin falling to 5 or 6 g/dl, and requiring regular blood transfusions to maintain a more respectable haemoglobin. The white cell and platelet counts are characteristically normal, but there is usually a profound decrease in circulating reticulocytes (to

Anaemia is one of the most serious complications of renal dysfunction and is associated with severe, often life-threatening clinical sequelae including cardiovascular disease [1]. Anaemia of renal insufficiency originates from a reduced ability of the kidney to produce the protein hormone erythropoietin (EPO), which is responsible for the initiation of red blood cell (RBC) production from precursor cells produced by the bone marrow. Currently, European Best Practice Guidelines for the Management of Anaemia in Patients with Chronic Renal Failure recommend that treatment of renal anaemia should be achieved by the supplementation of endogenous EPO with recombinant human EPO (rHuEPO), which stimulates erythropoiesis, thereby inducing a rise in haemoglobin (Hb) concentrations [2]. Usually, rHuEPO therapy is given two or three times per week and can be administered by the intravenous or subcutaneous routes in patients undergoing haemodialysis (HD) or subcutaneously in patients receiving peritoneal dialysis (PD). Darbepoetin alfa (Aranesp, Amgen, Inc.) is an erythropoiesis-stimulating protein that is molecularly distinct from rHuEPO. It is super-sialated, which leads to a longer serum half-life than that of rHuEPO [3,4], resulting in extended in vivo erythropoietic activity. Darbepoetin alfa can be given less frequently and can be used subcutaneously or intravenously with the same, or equivalent Hb responses and dosing [7], offering simplified dosing for new patients and those currently treated with rHuEPO. Clinical trials with darbepoetin alfa began in 1997 and this brief article reports on two patients whose long-term anaemia management has been simplified by its use.

This is part 2 of a two-part unit on managing anaemia of chronic kidney disease (CKD). Part 1 outlined its prevalence, causes, signs and symptoms, and screening for it. Part 2 presents key points from published guidance and a summary of treatment options, and discusses nurses' role in managing people who have anaemia in CKD.

This is a two-part unit on managing anaemia in chronic kidney disease. Part 1 outlines the prevalence, causes and signs and symptoms of the condition, which, until recently, was underrecognised and under-treated.