肾性贫血治疗指南

肾性贫血治疗指南CPR1.1.IDENTIFYINGPATIENTSANDINITIATINGEVALUATION1.1.1StageandcauseofCKD:IntheopinionoftheWorkGroup,HbtestingshouldbecarriedoutinallpatientswithCKD,regardlessofstageorcause.1.1.2Frequencyoftestingforanemia:IntheopinionoftheWorkGroup,Hblevelsshouldbemeasuredatleastannually.1.1.3Diagnosisofanemia:IntheopinionoftheWorkGroup,diagnosisofanemiashouldbemadeandfurtherevaluationshouldbeundertakenatthefollowingHbconcentrations:●13.5g/dLinadultmales.（12.0g/dL）●12.0g/dLinadultfemales.（11.0g/dL）贫血定义WHO的贫血诊断标准：成人女性血红蛋白（Hb）120g/L成人男性Hb130g/L但应考虑患者年龄、种族、居住地的海拔高度和生理需求对Hb的影响。注：肾性贫血主要为促红细胞生成素不足导致，只有如下各条内容均具备才能下临床诊断：①患者患有慢性肾脏病(CKD），并已有肾功能损害；②Hb已达到上述贫血诊断标准；③能够除外CKD以外因素所致贫血。注：2004年EBPG及2006年K/DOQI均明确指出，在评估贫血时，检测Hb浓度比检测Hct更容易、更稳定、更可靠，所以近年肾性贫血诊疗指南都再不用Hct诊断贫血。血液透析患者血标本应在血透开始前或刚开始血透时即刻采集。CPR1.2.EVALUATIONOFANEMIAINCKD1.2.1IntheopinionoftheWorkGroup,initialassessmentofanemiashouldincludethefollowingtests:1.2.1.1Acompletebloodcount(CBC)including—inadditiontotheHbconcentration—redbloodcellindices(meancorpuscularhemoglobin[MCH],meancorpuscularvolume[MCV],meancorpuscularhemoglobinconcentration[MCHC]),whitebloodcellcount,anddifferentialandplateletcount.1.2.1.2Absolutereticulocytecount.1.2.1.3Serumferritintoassessironstores.1.2.1.4SerumTSATorcontentofHbinreticulocytes(CHr)toassessadequacyofironforerythropoiesis.贫血实验室检查内容血红蛋白/红细胞压积（Hb/Hct）红细胞指标（红细胞计数、平均红细胞体积、平均红细胞血红蛋白量、平均红细胞血红蛋白浓度等）网织红细胞计数（有条件提倡检测网织红细胞血红蛋白量）铁参数（血清铁、总铁结合力、转铁蛋白饱和度、血清铁蛋白）大便粪隐血试验。注：慢性肾脏病时的贫血一般是正细胞和正色素性的。小细胞性贫血说明存在铁缺乏、铝过多或某种血红蛋白病。大细胞性贫血则可能与叶酸和维生素B12缺乏有关，或者也可能是铁过多和(或)EP0治疗导致未成熟的、大的网织红细胞进入循环。血清铁和转铁蛋白饱和度反映即刻可以用作合成血红蛋白的铁量。血清铁蛋白反映了总的机体内铁储存。如果TSAT16％和(或)血清铁蛋白小于12g／L则诊断绝对铁缺乏。肾性贫血的检查流程CPGANDCPR2.1.HBRANGE2.1.1LowerlimitofHb:InpatientswithCKD,Hbshouldbe11.0g/dLorgreater.(MODERATELYSTRONGRECOMMENDATION)2.1.2UpperlimitofHb:IntheopinionoftheWorkGroup,thereisinsufficientevidencetorecommendroutinelymaintainingHblevelsat13.0g/dLorgreaterinESA-treatedpatients.2.1HEMOGLOBINTARGET20072.1.1IntheopinionoftheWorkGroup,selectionoftheHbtargetandselectionoftheHblevelatwhichESAtherapyisinitiatedintheindividualpatientshouldincludeconsiderationofpotentialbenefits(includingimprovementinqualityoflifeandavoidanceoftransfusion)andpotentialharms(includingtheriskoflifethreateningadverseevents).(ClinicalPracticeRECOMMENDATION)2.1.2IntheopinionoftheWorkGroup,indialysisandnondialysispatientswithCKDreceivingESAtherapy,theselectedHbtargetshouldgenerallybeintherangeof11.0to12.0g/dL.(ClinicalPracticeRECOMMENDATION)2.1.3IndialysisandnondialysispatientswithCKDreceivingESAtherapy,theHbtargetshouldnotbegreaterthan13.0g/dL.(ClinicalPracticeGUIDELINE–MODERATELYSTRONGEVIDENCE)rHuEPO治疗肾性贫血靶目标值Hb110～120g/L(Hct33~36%)，建议Hb不超过130g/L。靶目标值应在开始治疗后4个月内达到，并依据患者年龄、种族、性别、生理需求以及是否合并其他疾病进行个体化调整：伴有缺血性心脏病、充血性心力衰竭等心血管疾病的患者不推荐Hb120g/L；糖尿病的患者，特别是并发外周血管病变的患者，需在监测下谨慎增加Hb水平至120；合并慢性缺氧性肺疾病患者推荐维持较高的Hb水平。注：Hb治疗目标值上限,在2007年K/DOQI补充材料发表前一直不明朗。于2006年K/DOQI修订版发布后一年间，又有5个研究Hb靶目标值的大型临床随机对照试验完成，治疗观察例数增加了一倍，在此基础上进行荟萃分析即清晰发现，Hb目标值＞130g/L时发生威胁生命的不良事件风险会显著增加，如此才获得了上述结论。CPR3.1.USINGESAs3.1.1FrequencyofHbmonitoring:3.1.1.1IntheopinionoftheWorkGroup,thefrequencyofHbmonitoringinpatientstreatedwithESAsshouldbeatleastmonthly.3.1.2.1IntheopinionoftheWorkGroup,theinitialESAdoseandESAdoseadjustmentsshouldbedeterminedbythepatient’sHblevel,thetargetHblevel,theobservedrateofincreaseinHblevel,andclinicalcircumstances.3.1.2.2IntheopinionoftheWorkGroup,ESAdosesshouldbedecreased,butnotnecessarilywithheld,whenadownwardadjustmentofHblevelisneeded.CPR3.1.USINGESAs3.1.2ESAdosing3.1.2.3IntheopinionoftheWorkGroup,scheduledESAdosesthathavebeenmissedshouldbereplacedattheearliestpossibleopportunity.3.1.2.4IntheopinionoftheWorkGroup,ESAadministrationinESA-dependentpatientsshouldcontinueduringhospitalization.3.1.2.5IntheopinionoftheWorkGroup,hypertension,vascularaccessocclusion,inadequatedialysis,historyofseizures,orcompromisednutritionalstatusarenotcontraindicationstoESAtherapy.CPR3.1.USINGESAs3.1.3Routeofadministration:3.1.3.1IntheopinionoftheWorkGroup,therouteofESAadministrationshouldbedeterminedbytheCKDstage,treatmentsetting,efficacy,safety,andclassofESAused.3.1.3.2IntheopinionoftheWorkGroup,conveniencefavorssubcutaneous(SC)administrationinnon-HD-CKDpatients.3.1.3.3IntheopinionoftheWorkGroup,conveniencefavorsintravenous(IV)administrationinHD-CKDpatients.CPR3.1.USINGESAs3.1.4Frequencyofadministration:3.1.4.1IntheopinionoftheWorkGroup,frequencyofadministrationshouldbedeterminedbytheCKDstage,treatmentsetting,efficacyconsiderations,andclassofESA.3.1.4.2IntheopinionoftheWorkGroup,conveniencefavorslessfrequentadministration,particularlyinnon–HD-CKDpatients.rHuEPO的临床应用使用时机:无论透析还是非透析的慢性肾脏病患者，若间隔2周或者以上连续两次Hb检测值均低于110g/L，并除外铁缺乏等其它贫血病因，应开始实施rHuEPO治疗。使用途径:rHuEPO治疗肾性贫血，静脉给药和皮下给药同样有效。但皮下注射的药效动力学表现优于静脉注射，并可以延长有效药物浓度在体内的维持时间，节省治疗费用。皮下注射较静脉注射疼痛感增加。对非血液透析的患者，推荐首先选择皮下给药。对血液透析的患者，可以选择静脉给药，也可选皮下注射。静脉给药可减少疼痛，增加患者依从性；而皮下给药可减少给药次数和剂量，节省费用。对腹膜透析患者，由于生物利用度的因素，不推荐腹腔给药。rHuEPO的临床应用使用剂量:初始剂量皮下给药：100-120IU/Kg/W。静脉给药：120-150IU/Kg/W。初始剂量选择要考虑患者的贫血程度和导致贫血的原因，对于Hb70g/L的患者，应适当增加初始剂量。对于非透析患者或残存肾功能较好的透析