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The Renal National Service Framework (NSF), and the subsequent NICE Clinical Practice Guideline for early identification and management of adults with chronic kidney disease (CKD) in primary and secondary care (CG73), served to emphasise the change in focus in renal medicine from treatment of established kidney disease to earlier identification and prevention of kidney disease.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: July 2014

People who have chronic kidney disease (CKD) frequently experience anaemia. Several different medicines that treat anaemia are available including darbepoetin alfa.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Anaemia, which occurs when red blood cell and haemoglobin levels fall below normal, is a common problem among adults with chronic kidney disease (CKD). Anaemia can cause breathlessness, dizziness and chest pain (angina); reduce ability to think clearly; limits ability to exercise; and contributes to sexual problems, poor appetite and reduced quality of life. Anaemia may also cause longer hospital stays, and sometimes death.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Several drugs are available to treat anaemia for people who have kidney disease but whether these drugs are similar or different in their ability to improve symptoms of anaemia, such as tiredness and breathlessness, and whether they are equally safe based on their risks of causing a stroke or a heart attack, is not clear. This is because research studies that compare the effects of one drug directly with another are not common. We have found 56 studies that measure the safety and how these drugs help to improve how patients who have kidney disease feel, function and survive that have involved 15,596 people. Our last search of the literature was in February 2014.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Chronic heart failure is a disorder in which the heart is unable to pump blood and deliver oxygen adequately throughout the body.  Patients with heart failure may also suffer from anaemia, a condition of reduced red blood cells and diminished ability of the blood to carry oxygen.  These patients appear to have worse symptoms and poorer survival and may benefit from additional therapy for their anaemia.  Erythropoiesis‐stimulating agents (ESAs) with iron supplements have been used since the 1980s to treat anaemia in chronic kidney disease and cancer patients.  ESAs have the same action as erythropoietin, a hormone that is naturally produced by the kidneys to increase red blood cell production.  This review shows that ESAs improves anaemia, exercise tolerance, quality of life and reduces symptoms in heart failure patients with a mild anaemia.  ESAs may also reduce hospital admission and improve survival.  There was no increase in major side effects in those receiving ESA therapy compared to control over the 2‐12 month study period (maximum 12 months) although the effects of treatment over a longer period are not known. More research is needed to clarify the full effects and safety of ESAs as a treatment for anaemia in these patients.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Anaemia (low haemoglobin) is a common complication among people with end‐stage kidney disease (ESKD) receiving dialysis treatment. Dialysis treatment removes toxic waste products from the blood when kidneys no longer function. Anaemia treatment is based on the use of manufactured erythropoietin (EPO, a hormone that increases haemoglobin), to improve fatigue and breathlessness which are common symptoms of severe anaemia. It is widely accepted that EPO treatment should be initiated when haemoglobin levels are less than or equal to 10 g/dL (delayed onset). However, it remains unknown if there are clinical benefits or harms when EPO treatment is commenced when haemoglobin levels are greater than 10 g/dL but less than 11 g/dL (early onset).

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2017

The aim of this review was the evaluation of studies on allogeneic stem cell transplantation with an unrelated donor vs. immunosuppressive therapy in patients with acquired severe aplastic anaemia. The focus of the evaluation was on patient-relevant therapy goals.

Institute for Quality and Efficiency in Health Care: Executive Summaries [Internet] - Institute for Quality and Efficiency in Health Care (IQWiG).

Version: February 14, 2007

Many people with chronic kidney disease (CKD) who are on dialysis develop anaemia (too few or poor quality red blood cells). Drugs in the erythropoiesis‐stimulating family increase the production of red blood cells to resolve anaemia. Although ESAs have been highly beneficial for many, about 10% of people get either low or no benefit from treatment. Inability to control and stabilise anaemia can lead to poor rates of survival and increased risk of stroke so it is important to find effective treatment to manage anaemia in people who do not respond adequately to ESA therapy.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Anaemia is defined internationally as a state in which the quality and/or quantity of circulating red blood cells is below normal. Blood haemoglobin (Hb) concentration serves as the key indicator for anaemia because it can be measured directly and has an international standard. In response to low tissue oxygen levels in anaemia the kidney produces the hormone erythropoietin which stimulates the bone marrow to produce red blood cells. A major cause of the anaemia of chronic kidney disease (CKD) is a reduction in erythropoietin production due to kidney damage.

NICE Guideline - National Clinical Guideline Centre (UK).

Version: June 2015

‐ it is uncertain whether erythropoiesis‐stimulating agents improve quality of life or hemoglobin levels.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Several treatments are available to treat anaemia in people who have kidney disease. These treatments boost the body's ability to produce red blood cells that take oxygen from the lungs and carry oxygen around the body. The kidney normally releases this hormone that prevents anaemia, but when the kidney function is low this hormone is insufficient to maintain an optimal level of red blood cells.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: August 7, 2017

Anemia is very common in congestive heart failure (CHF) and coronary heart disease (CHD) patients. Anemia in CHF and CHD patients is associated with poorer outcomes, including an increased risk of hospitalization, decreased exercise capacity, and poor quality of life. Despite the association with poorer outcomes, it is unclear whether treating anemia or iron deficiency will improve outcomes. Anemia treatment strategies in heart failure and CHD patients include erythropoiesis-stimulating agents (ESAs) and red blood cell transfusions. Iron replacement in iron deficient patients with or without anemia has also been investigated. The objective of this evidence review is to evaluate the balance of benefit and harms of these treatments.

Evidence-based Synthesis Program - Department of Veterans Affairs (US).

Version: October 2011

Ferumoxytol (Feraheme) is a colloidal superparamegnetic iron-carbohydrate complex that was specifically designed to reduce immunological reactivity. It can be rapidly administered (IV rate of 30–60 seconds) as a 510 mg dose with the second IV injection administered two to eight days later. The federal Food and Drug Administration (FDA) in the United States has listed ferumoxytol for the treatment of iron deficiency anemia (IDA, characterized by iron deficiency) in adult patients with chronic kidney disease (CKD). Health Canada has recently placed restrictions on the use of ferumoxytol due to the potential for serious allergic reactions. Therefore, this review was performed to assess the clinical effectiveness and safety of ferumoxytol compared with other IV iron therapies for patients with IDA. In addition, cost-effectiveness and evidence-based guidelines were also investigated to determine the costs associated with ferumoxytol and its use in patients with IDA. This is an update to a previous review on ferumoxytol which found limited evidence that stated that it seemed to have comparable efficacy to other iron complexes but that it was associated with an increased adverse event profile.

Rapid Response Report: Summary with Critical Appraisal - Canadian Agency for Drugs and Technologies in Health.

Version: November 21, 2014

Oral iron salts such as ferrous fumarate, ferrous gluconate, and ferrous sulfate have been the mainstay of oral iron supplementation because they are inexpensive, effective at restoring iron balance, and have good overall safety and tolerability profile. However, in some patients, absorption of oral iron salts is inadequate, and poor tolerance results in reduced adherence to therapy. Polysaccharide iron complex and heme iron polypeptide products have become available as alternative therapies, offering improved absorption and tolerability profile over the traditional iron salts. However, they are significantly more expensive than iron salts. The aim of this review is to summarize current evidence on the comparative clinical and cost effectiveness of oral and injectable iron supplementation products for iron deficiency anemia (IDA).

Rapid Response Report: Summary with Critical Appraisal - Canadian Agency for Drugs and Technologies in Health.

Version: January 6, 2016

The review assessed the clinical effectiveness and cost-effectiveness of deferasirox for the treatment of iron overload in chronically transfused anaemic patients.

NIHR Health Technology Assessment programme: Executive Summaries - NIHR Journals Library.

Version: 2009

Bibliographic details: Chung M, Moorthy D, Hadar N, Salvi P, Iovin RC, Lau J.  Biomarkers for assessing and managing iron deficiency anemia in late-stage chronic kidney disease. Rockville, MD, USA: Agency for Healthcare Research and Quality. Comparatvie Effectiveness Review; 83. 201223230575

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2012

The study found that erythropoiesis-stimulating agents could be cost-effective for treating cancer treatment-induced anaemia when used closer to licence but that there is considerable uncertainty, mainly because of unknown impacts on overall survival.

Health Technology Assessment - NIHR Journals Library.

Version: February 2016

Increased involvement of clinical pharmacists in patient care may offer increased access to health care and improved patient outcomes. Defined by Hepler and Strand in 1989, pharmaceutical care involves pharmacist collaboration with health team members to optimize therapeutic outcomes by identifying, solving, and preventing actual and potential drug therapy problems. Since 1995, the Department of Veterans Affairs has allowed Clinical Pharmacy Specialists (CPS) an expanded scope of practice with independent prescribing privileges. In this capacity, CPS have been detailed to perform “pharmaceutical care” or comprehensive medication management along with chronic disease state management services, in addition to less complex services such as patient medication counseling or responding to drug information questions. In the VA primary care setting, CPS are likely to be responsible for therapeutic outcomes for a multitude of conditions for any patient referred to CPS or proactively identified by CPS as a high-risk patient.

Evidence-based Synthesis Program - Department of Veterans Affairs (US).

Version: October 2015

We reviewed the evidence to see if regular long‐term red blood cell transfusions helped to reduce the occurrence or progression of chronic chest complications compared to hydroxycarbamide (hydroxyurea), any other treatment or standard care in people with sickle cell disease.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2016

Anaemia due to reduced production by the kidneys of erythropoietin (a hormone which increases red cell production) is a major cause of tiredness and other problems experienced by people with chronic kidney disease requiring or not requiring dialysis.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2017

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