- Email: [email protected]
Anemia & CKD
6
Anemia & CKD “I felt everyone there was well informed and friendly. Everything was conducted very professionally. My results were explained in good detail and when I saw my doctor, I was informed enough to ask her for the tests I needed to address my concerns. Since the screening, I have kept an eye on my iron and have a lot more energy. I even lost about 15 lbs since the screening. One of my resolutions is to start taking better care of myself. Thank you for this program!” KEEP Participant: Screening date, August, 2005
general anemia anemia & CKD odds of anemia
Chapter 6 «» Anemia and CKD
s79
Percent of participants Percentwith of participants anemia with anemia
general anemia
25 KEEP: Age
15
25 KEEP: Age 10 WHO anemia 20 K/DOQI anemia 5
10
NHANES: Age
Gender
Gender
NHANES: Age
Gender
WHO anemia K/DOQI anemia
20
15 0
Gender
All
18-30
31-45
46-60
61-75
75+
Male
Female
All
18-30
31-45
46-60
61-75
75+
Male
Female
All
18-30
31-45
46-60
61-75
75+
Male
Female
All
18-30
31-45
46-60
61-75
75+
Male
Female
5 0
6.1
Anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by age & gender
Percent of participants Percentwith of participants anemia with anemia
KEEP N= 52,317. NHANES N= 10,018. 20 KEEP
NHANES 99-02 WHO anemia K/DOQI anemia
15 10 20 KEEP
NHANES 99-02 WHO anemia K/DOQI anemia
155 100
White
Black
Other
Hisp. Non-Hisp.
White
Black
Other
Hisp. Non-Hisp.
Anemia 0 (WHO & K/DOQI definitions) White Black participants, Other Hisp. by Non-Hisp. in KEEPWhite & NHANES race/ethnicity
Black
Other
Hisp. Non-Hisp.
6.2
5
KEEP N= 51,207. NHANES N= 10,018.
he percentage of KEEP and NHANES participants with WHO and K/DOQI anemia increases with age, reaching 20 and 15%, respectively, in participants age 75 and older. For both definitions, anemia is more prominent in females compared to males—13.2 versus 8.8%, respectively, using the WHO anemia defini tion and 9.1 versus 3%, respectively using the K/DOQI definition. Blacks exhibit the highest rates of anemia in both populations. In black KEEP participants, and using the WHO and
s80
K/DOQI anemia definitions, rates reach 18.5 and 11.1%, respectively, compared to 7.9 and 5% in whites. By age and education status, older KEEP and NHANES participants generally have the highest percentages of WHO and K/DOQI anemia; anemia is most prominent in black participants. KEEP participants who are anemic are more likely to have a positive urinary microalbumin, higher microalbumin levels, and a greater likelihood of an abnormal ACR (≥30 mg/g).
National Kidney Foundation «» Kidney Early Evaluation Program «» 2006
0
Race/ethnicity Race/ethnicity Race/ethnicity
White White Black Black
Other Other Hispanic Hispanic
White Black
Other Hispanic
6.3
Anemia (WHO definition) in KEEP & NHANES participants, by education & insurance status, age, & race/ethnicity
Percent with Percent anemia with (K/DOQI anemia definition) (K/DOQI definition) Percent with anemia (K/DOQI definition)
KEEP N= 49,694, age; 48,749, race. NHANES N= 9,856. *Sample size less than 30 or coefficient of variation not less than 30%. 25 KEEP: Age 25 KEEP: Age 20 20 25 KEEP: Age 15
Race/ethnicity Race/ethnicity Race/ethnicity
15 20 10 10 155 5 100 0 255 NHANES 99-02 99-02 25 NHANES18-45 White Other 200 18-45 White Other Black Hispanic 46-60 20 NHANES 99-02 Black Hispanic 46-60 61+ 25 15 61+ 18-45 White Other 15 20 10 Black Hispanic 46-60 * 10 * 61+ * * 155 * * * * * * * ** * * 5 * * * * * * * * * * * 100 ** * * *
by age, race/ethnicity, education, & insurance status KEEP N= 49,694, age; 48,749, race. NHANES N= 9,856. *Sample size less than 30 or coefficient of variation not less than 30%.
Chapter 6 «» Anemia and CKD
Percent w noitathw lbim tuhm iaaulm buinm Mean microalbumin Mean microalbumin level (mg/L) level (mg/L) Percent with Percent abnormal with ACR abnormal icm PeitrhPceemrncitcerw rin oicuarrlob uirniauria Mean microalbumin level (mg/L) Percent with abnormal ACRACR
Percent with Percent anemia with (WHO anemia definition) (WHO definition) Percent with anemia (WHO definition)
25 KEEP: Age 25 KEEP: Age 20 20 KEEP: Age 25 15 15 20 10 10 155 5 100 0 255 NHANES 99-02 99-02 25 NHANES18-45 18-45 200 46-60 20 NHANES 61+ 46-60 99-02 25 15 61+ 18-45 15 20 46-60 10 * 10 61+ * 155 * * 5 100 * 0
6.5
60 60 40 60 40 20 40 20 0 20 0 50 0 50 40 40 50 30
WHO definition WHO definition K/DOQI definition K/DOQI definition No Yes WHO definition Yes No K/DOQI definition No
Yes
No No
Yes Yes
No
Yes
No No
Yes Yes
No
Yes
30 40 20 20 30 10 10 200 0 10 25 0 25 20 20 25 15 15 20 10 10 155 5 100 0 5 0
Microalbuminuria & ACR in KEEP participants with anemia (WHO & K/DOQI definitions) KEEP N= 52,317, microalbumin; 47,612, microalbumin level; 43,580, ACR. Positive microalbumin >20mg/L
s81
KEEP NHANES 99-02
11.8
10 5 0
7.4
5.6
2.5
All
CKD
No CKD
All
CKD
No CKD
15
0 20
Percent of participants with anemia
15
K/DOQI anemia
Percent of participants with anemia Percent of participants with anemia
Percent of participants with anemia
anemia & ckd 20 WHO anemia
5
K/DOQI anemia
15 20 10 WHO anemia 155 100 5 0
6.6
K/DOQI anemia KEEP NHANES 99-02
11.8 All 5.6
CKD
No CKD
7.4All
CKD
No CKD
CKD
No CKD
All
5 0 20
K/DOQI anemia
15 10 5
2.5
All
10
CKD
0
No CKD
All
Anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by CKD status KEEP N= 44,723. NHANES N= 10,018, all, 9,712 CKD.
WHO anemia: KEEP
NHANES 99-02 Male Female
15
WHO anemia: KEEP
NHANES 99-02
20
10
Percent of participants with anemia
Percent of participants with anemia
30
5 0
K/DOQI anemia 20 15 10
30
20 0 30
K/DOQI anemia
White Black Other
20
10
5 0
CKD
0
All
CKD
No CKD
All
CKD
No CKD
All
CKD
No CKD
All
CKD
No CKD
6.7
6.8
Anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by CKD status & gender
Anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by CKD status & race
KEEP N= 44,723. NHANES N= 10,018, all; 9,712, CKD.
KEEP N= 43,823. NHANES N= 10,018, all; 9,712, CKD.
30
WHO anemia: KEEP
Percent of participants with anemia
20
10
0 30
K/DOQI anemia
NHANES 99-02
nder WHO and K/DOQI anemia definitions, 17.3 and 12.9% of KEEP participants with CKD are classified as anemic, and female participants are generally most likely to have anemia regardless of CKD status. By race, black participants are most likely to have anemia. In KEEP and NHANES participants with CKD, for example, 26 and 24%, respectively, are anemic using the WHO anemia definition and 19.6 and 11.2% are White classified as anemic when using Black the K/DOQI definition. Other
20
Of KEEP and NHANES participants with WHO or K/DOQI anemia, 77.9 and 81.8% in KEEP are classified as having Stage 3–5 CKD compared to 40.9 and 57.3% in the NHANES population. KEEP participants in the later stages of CKD are most likely to have anemia. Within all stages of CKD, black KEEP participants are the most likely to have anemia. KEEP participants with diabetes are generally the most likely to be classified as anemic, when using the WHO and K/DOQI anemia definitions.
10
s82
0
All
CKD
No CKD
All
National Kidney Foundation «» Kidney Early Evaluation Program «» 2006
CKD
No CKD
WHO anemia:
10
Percent of participants with anemia
20
10
0 30
K/DOQI anemia
20
10
0
All
NHANES: WHO anemia NHANES: WHO anemia NHANES: WHO anemia
.0 13 2: e 0 . g Sta : 1 3 . 0 Stage 1: 46.9 1 3 1: 9.2 e 2Stage : g Stage 2: 12.2 Sta ge 2 Stage 1: 46.9 StaStage 1: 9.2 Stage 1: 9.2 Stage 2: 12.2 Stage 1: 46.9 Stage 2: 12.2 Stages 3-5: 77.9 Stage 3-5: 40.9
Stages 3-5: 77.9 Stages 3-5: 77.9
Stage 3-5: 40.9 Stage 3-5: 40.9
KEEP: K/DOQI anemia
NHANES: K/DOQI anemia
KEEP: K/DOQI anemia KEEP: K/DOQI anemia 1.1 2: 1 ge Sta 11.1 : 1 e 2 11:1.7.1 gStage Sta ge 2: a t S Stage 1: 7.1 Stage 1: 7.1 Stages 3-5: 81.8
NHANES: K/DOQI anemia NHANES: K/DOQI anemia Sta ge 2: 9 . 7* Sta g Stae 2: ge 9.7 2: 9* . 7*
Stage 1: 33.0
Stage 1: 33.0 Stage 1: 33.0 Stages 3-5: 57.3
Stages 3-5: 81.8 Stages 3-5: 81.8
Stages 3-5: 57.3 Stages 3-5: 57.3
80
WHO anemia: KEEP
WHO anemia: KEEP Male 80 WHO anemia: KEEP 80 60
60 60 40
Percent of participants with anemia PercentPercent of participants of participants with anemia with anemia
KEEP: WHO anemia KEEP: WHO anemia KEEP: WHO anemia
Female Male Male Female Female
40 40 20
30
NHANES 99-02
NHANES 99-02 30 NHANES 99-02
080 K/DOQI anemia 0 80 K/DOQI anemia 80 K/DOQI anemia 60 60 60 40
*
20 20 10
*
*
* * *
030 0 30 30 20
*
*
* *
20 20 10
40 40 20
*
*
*
10 10 0
20 200
*
30 20
*
* * ** * * * *1 * Stage 3-5 All Stage 1 Stage 3 All *Stage 0 0 * 2 NCKD Stage 2 Stage 4-5 NCKD * Stage 0 All 0 All Stage 1 Stage 3 Stage 1 Stage 3-5 All Stage 1 2Stage 3 4-5 All NCKD Stage 1 2Stage 3-5 NCKD Stage Stage Stage NCKD Stage 2 Stage 4-5 NCKD Stage 2 10 10 0
20 200
6.9
6.10
Percent distribution of KEEP & NHANES participants with WHO & K/DOQI anemia, by CKD stage
Anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by CKD stage & gender
KEEP N= 2,217, WHO anemia; 1,645, K/DOQI anemia. NHANES N= 1,504. *Sample size less than 30 or coefficient of variation not less than 30%.
KEEP N= 44,723. NHANES N= 10,018, all; 9,712, CKD. *Sample size less than 30 or coefficient of variation not less than 30%.
WHO anemia: KEEP
WHO anemia: KEEP White 80 WHO anemia: KEEP Black 80 60 White Other White Black 60 Hispanic Black 60 40 Other Other Hispanic 40 Hispanic 40 20
50
NHANES 99-02
NHANES 99-02
Percent of participants with anemia PercentPercent of participants of participants with anemia with anemia
5040 NHANES 99-02 50 4030 40 * * 3020 30 * * * * 2010 * 20 * * ** * ** * 20 10 200 0 10 * ** * ** K/DOQI anemia * ** * ** 060 050 0 K/DOQI anemia 0 60 5040 K/DOQI anemia 60 50 40 4030 40 * 40 3020 40 * * * 30 20 * * 2010 * 20 * 20 * 20 ** * * * 10 0 * 0 10 All All Stage 1 Stage 3 Stage ** *1 * * Stage 3-5 * ** Stage 0 NCKD NCKD Stage 2 Stage 4-5 0 * *2 * All Stage 1 Stage 3 All Stage 1 * Stage 3-5 0 0 All Stage 1 Stage 3 All Stage 1 NCKD NCKD Stage 2 Stage 4-5 Stage 2Stage 3-5 6.11 NCKD NCKD Stage 2 Stage 4-5 Stage 2
Anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by CKD stage & race/ethnicity KEEP N= 43,823. NHANES N= 10,018, all. *Sample size less than 30 or coefficient of variation not less than 30%.
Chapter 6 «» Anemia and CKD
80 80 80 60 60 60 40
Percent of participants with anemia PercentPercent of participants of participants with anemia with anemia
80
WHO anemia: KEEP WHO anemia: KEEP Diabetics WHO anemia: KEEP
Non-diabetics Diabetics Diabetics Non-diabetics Non-diabetics
40 40 20 20 200 080 K/DOQI anemia 0 80 K/DOQI anemia 80 K/DOQI anemia 60 60 60 40 40 40 20
30
NHANES 99-02
NHANES 99-02
30 NHANES 99-02 30 20 20 20 10
* *
10 10 0
*
*
*
030 0 30 30 20
* *
* *
20 20 10 10 10 0
* *
*
*
* * * * * * * * * 1 * Stage 3-5 All Stage 1 Stage 3 All Stage * * * Stage 0 NCKD NCKD Stage 2 Stage 4-5 0 2 Stage 1 Stage 3 Stage 1 Stage 3-5 0 All 0 All All Stage 1 Stage 3 All Stage 1 Stage 3-5 NCKD NCKD Stage 2 Stage 4-5 Stage 2 6.12 NCKD NCKD Stage 2 Stage 4-5 Stage 2 20 200
*
Anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by CKD stage & self-reported diabetic status KEEP N= 44,342. NHANES N= 10,013. *Sample size less than 30 or coefficient of variation not less than 30%.
s83
odds of anemia
Odds ratio of anemia
8 WHO anemia KEEP NHANES 99-02 6 4
2 60-<90
≥90
Odds ratio of anemia
6 WHO anemia
4
18-30
(ml/min/1.73m2) 0
≥90
60-<90
6 WHO anemia
2
0
<60
K/DOQI anemia
KEEP NHANES 99-02 K/DOQI anemia
31-45
46-60
≥90
<60
75+
61-75
18-30
31-45
Odds ratio of anemia
K/DOQI anemia
61-75
0
<60
60-<90
KEEP NHANES 99-02
4
2 46-60
K/DOQI anemia
18-30
eGFR (ml/min/1.73m ) 2
75+
31-45
46-60
61-75
75+
18-30
31-45
46-60
61-75
6.13
6.14
Odds ratio of anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by eGFR
Odds ratio of anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by age
KEEP N= 44,075. NHANES N=8,707, participants age 20 and older.
KEEP N= 44,075, NHANES N=8,707, participants age 20 and older.
K/DOQI anemia: Diabetic
KEEP NHANES 99-02
15 10 5 0
6.15
Non-diabetic
White Black Other
White Black Other
Non-diabetic
20 WHO anemia:Diabetic
Odds ratio of anemia
Odds ratio of anemia
20 WHO anemia:Diabetic
75+
Non-diabetic
K/DOQI anemia: Diabetic
Non-diabetic
White Black Other
White Black Other
KEEP NHANES 99-02
15 10
5 Black Other White 0
White Black Other
White Black Other
White Black Other
Odds ratio of anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by race & self-reported diabetic status KEEP N= 44,075. NHANES N= 8,707, participants age 20 and older.
he odds of having anemia are greatest in participants with eGFRs of less than 60 ml/min/1.73 m2. In the KEEP population, for example, the odds of anemia in participants with eGFRs of less than 60 ml/min/1.73 m2, are 80% (WHO) and 100% (K/DOQI) higher when compared to those with an eGFR equal to or greater than 90 ml/ min/1.73 m2. KEEP participants age 75 and older are more than two times as likely to have anemia compared to those age 46–60. By either the WHO or K/DOQI anemia
s84
definition, both black diabetic and nondiabetic KEEP participants are 3–5 times more likely to be anemic compared to white non-diabetics. KEEP and NHANES participants age 75 and older are more than twice as likely to be anemic compared to participants age 46–60. Diabetes is a significant risk factor for anemia. Black diabetics, for example, are five to ten times more likely to be anemic compared to white non-diabetics. Participants with eGFRs <60 are 2–4 times more likely to be anemic compared to those with eGFRS of 90+.
National Kidney Foundation «» Kidney Early Evaluation Program «» 2006
WHO anemia
7 6
WHO anemia
5 7 4 6 3 5 2 4
Odds ratio Odds of anemia ratio of anemia
WHO anemia K/DOQI anemia OR CI P-value OR CI P-value Age (ref: 46-60) 18-30 1.18 (1.03-1.34) 0.0147 0.47 (0.38-0.59) <.0001 31-45 1.45 (1.33-1.57) <.0001 0.81 (0.72-0.91) 0.0005 61-75 1.19 (1.10-1.30) <.0001 1.37 (1.25-1.52) <.0001 >75 2.26 (2.02-2.53) <.0001 2.40 (2.11-2.73) <.0001 Male (ref: female) 0.65 (0.61-0.70) <.0001 0.31 (0.28-0.35) <.0001 Smoking & used to smoke 0.93 (0.88-0.99) 0.0243 0.92 (0.85-1.00) 0.0372 Self-reported HTN 1.12 (1.05-1.20) 0.0011 1.26 (1.15-1.37) <.0001 Family history DM 0.99 (0.93-1.06) 0.8233 0.99 (0.91-1.08) 0.7629 Family history EBP 0.98 (0.91-1.06) 0.6815 0.94 (0.85-1.04) 0.2384 BMI 30+ 1.03 (0.96-1.09) 0.4214 1.02 (0.94-1.10) 0.6458 eGFR (ref 90+) <60 1.81 (1.65-1.98) <.0001 2.06 (1.85-2.30) <.0001 60-<90 0.88 (0.82-0.95) 0.0006 0.86 (0.78-0.95) 0.0020 Race & diabetic status (ref: White/NDM) White/DM 2.13 (1.91-2.38) <.0001 2.14 (1.87-2.45) <.0001 Black/NDM 3.32 (3.04-3.62) <.0001 3.15 (2.81-3.53) <.0001 Black/DM 5.04 (4.52-5.62) <.0001 5.57 (4.88-6.36) <.0001 Other/NDM 1.42 (1.26-1.61) <.0001 1.51 (1.28-1.78) <.0001 Other/DM 2.69 (2.33-3.10) <.0001 3.06 (2.57-3.64) <.0001
1 3 0 2
K/DOQI anemia
1 7 0 6
K/DOQI anemia
5 7 4 6 3 5 2 4 1 3 0 2 1 0
Smoking eGFR: 90+ <60 White/DM Black/DM Other/DM SRHTN 60-<90 White/NDM Black/NDM Oth./NDM Smoking eGFR: 90+ <60 White/DM Black/DM Other/DM SRHTN 60-<90 White/NDM Black/NDM Oth./NDM
6.a
6.16
Odds ratio of anemia (WHO & K/DOQI definitions) in KEEP participants, by patient characteristics
Odds ratio of anemia (WHO & K/DOQI definitions) in KEEP participants, by race & risk factor
KEEP N= 44,075.
KEEP N= 44,075.
20 WHO anemia 15 WHO anemia 20 10 15 Odds ratio Odds of anemia ratio of anemia
WHO anemia K/DOQI anemia OR CI P-value OR CI P-value Age (ref: 46-60) 20-30 1.05 (0.70-1.56) 0.814 0.37 (0.23-0.61) 0.000 31-45 1.13 (0.82-1.55) 0.449 0.56 (0.34-0.93) 0.027 61-75 1.17 (0.78-1.76) 0.436 1.16 (0.72-1.88) 0.535 >75 2.02 (1.31-3.12) 0.002 2.29 (1.34-3.93) 0.004 Male (ref: female) 0.39 (0.31-0.48) 0.0001 0.26 (0.18-0.38) 0.0001 Smoking & used to smoke 0.85 (0.69-1.06) 0.146 0.99 (0.72-1.36) 0.949 Self-reported HTN 0.85 (0.66-1.08) 0.179 0.93 (0.63-1.39) 0.728 GFR (ref: 90+) <60 3.24 (2.16-4.87) 0.0001 4.78 (3.02-7.58) 0.0001 60-<90 0.79 (0.58-1.07) 0.127 1.11 (0.69, 1.80) 0.652 Race & diabetic status (ref: White/NDM) White/DM 2.32 (1.47-3.67) 0.001 2.16 (1.32-3.53) 0.003 Black/NDM 5.98 (4.55-7.86) 0.0001 7.08 (5.05-9.91) 0.0001 Black/DM 10.62 (6.26-18.0) 0.0001 10.37 (5.97-18.0) 0.0001 Other/NDM 2.19 (1.51-3.18) 0.0001 3.35 (1.85-6.07) 0.0001 Other/DM 4.24 (2.22-8.12) 0.0001 5.62 (2.33-13.52) 0.0001
5 10 0 5 K/DOQI anemia 20 0 15 K/DOQI anemia 20 10 15 5 10 0 5Smk/used GFR <60 Black/NDM Other/NDM to smoke SR HTN White/DM Black/DM Other/DM 0 Smk/used GFR <60 Black/NDM Other/NDM to smoke SR HTN White/DM Black/DM Other/DM
6.b
6.17
Odds ratio of anemia (WHO & K/DOQI definitions) in NHANES participants, by patient characteristics
Odds ratio of anemia (WHO & K/DOQI definitions) in NHANES participants, by race & risk factor
NHANES N=8,707, participants age 20 and older.
NHANES N= 8,707, participants age 20 and older.
Chapter 6 «» Anemia and CKD
s85
chapter highlights
Figure 6.1 The percentage of KEEP and NHANES participants with anemia increases with age, reaching 20 and 15%, respectively, in participants age 75 and older. Anemia is more prominent in females compared to males—13.2 versus 8.8% in the KEEP population. Figure 6.6 Under WHO and K/DOQI anemia definitions, 17.3 and 12.9% of KEEP participants with CKD are classified as anemic.
Anemia Definitions
WHO Male: hemoglobin <13 g/dl Female: <12g/dl K/DOQI Males: hemoglobin <12g/dl Women age >50: <12g/dl Women age ≤50: <11 g/dl
CKD Definition
If eGFR by K/DOQI MDRD <60 ml/ min/1.73 m2 or eGFR ≥60 ml/min/1.73 m2 and abnormal albumin/creatinine ratio (ACR ≥30mg/g)
Positive Microalbumin >20 mg/L
s86
Figure 6.9 Of KEEP and NHANES participants with WHO or K/DOQI anemia, 77.9 and 81.8% are classified as having Stage 3–5 CKD compared to 40.9 and 57.3% in the NHANES population. Table 6.a The odds of having anemia are greatest in participants with eGFRs of less than 60 ml/min/1.73 m2. In the KEEP population, for example, the odds of anemia in participants with eGFRs of less than 60 ml/min/1.73 m2 are 80–100% higher when compared to those with an eGFR equal to or greater than 90 ml/min/1.73 m2.
CKD Stages
Stage 1: eGFR ≥90, ACR ≥30 mg/g Stage 2: eGFR 60–89, ACR ≥30 mg/g Stage 3: eGFR 30–59 Stage 4: eGFR 15–29 Stage 5: eGFR <15 or dialysis
Abnormal albumin/creatinine ratio (ACR) ACR ≥30 mg/g
Education & insurance
National Kidney Foundation «» Kidney Early Evaluation Program «» 2006
Anemia & CKD “I felt everyone there was well informed and friendly. Everything was conducted very professionally. My results were explained in good detail and when I saw my doctor, I was informed enough to ask her for the tests I needed to address my concerns. Since the screening, I have kept an eye on my iron and have a lot more energy. I even lost about 15 lbs since the screening. One of my resolutions is to start taking better care of myself. Thank you for this program!” KEEP Participant: Screening date, August, 2005
general anemia anemia & CKD odds of anemia
Chapter 6 «» Anemia and CKD
s79
Percent of participants Percentwith of participants anemia with anemia
general anemia
25 KEEP: Age
15
25 KEEP: Age 10 WHO anemia 20 K/DOQI anemia 5
10
NHANES: Age
Gender
Gender
NHANES: Age
Gender
WHO anemia K/DOQI anemia
20
15 0
Gender
All
18-30
31-45
46-60
61-75
75+
Male
Female
All
18-30
31-45
46-60
61-75
75+
Male
Female
All
18-30
31-45
46-60
61-75
75+
Male
Female
All
18-30
31-45
46-60
61-75
75+
Male
Female
5 0
6.1
Anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by age & gender
Percent of participants Percentwith of participants anemia with anemia
KEEP N= 52,317. NHANES N= 10,018. 20 KEEP
NHANES 99-02 WHO anemia K/DOQI anemia
15 10 20 KEEP
NHANES 99-02 WHO anemia K/DOQI anemia
155 100
White
Black
Other
Hisp. Non-Hisp.
White
Black
Other
Hisp. Non-Hisp.
Anemia 0 (WHO & K/DOQI definitions) White Black participants, Other Hisp. by Non-Hisp. in KEEPWhite & NHANES race/ethnicity
Black
Other
Hisp. Non-Hisp.
6.2
5
KEEP N= 51,207. NHANES N= 10,018.
he percentage of KEEP and NHANES participants with WHO and K/DOQI anemia increases with age, reaching 20 and 15%, respectively, in participants age 75 and older. For both definitions, anemia is more prominent in females compared to males—13.2 versus 8.8%, respectively, using the WHO anemia defini tion and 9.1 versus 3%, respectively using the K/DOQI definition. Blacks exhibit the highest rates of anemia in both populations. In black KEEP participants, and using the WHO and
s80
K/DOQI anemia definitions, rates reach 18.5 and 11.1%, respectively, compared to 7.9 and 5% in whites. By age and education status, older KEEP and NHANES participants generally have the highest percentages of WHO and K/DOQI anemia; anemia is most prominent in black participants. KEEP participants who are anemic are more likely to have a positive urinary microalbumin, higher microalbumin levels, and a greater likelihood of an abnormal ACR (≥30 mg/g).
National Kidney Foundation «» Kidney Early Evaluation Program «» 2006
0
Race/ethnicity Race/ethnicity Race/ethnicity
White White Black Black
Other Other Hispanic Hispanic
White Black
Other Hispanic
6.3
Anemia (WHO definition) in KEEP & NHANES participants, by education & insurance status, age, & race/ethnicity
Percent with Percent anemia with (K/DOQI anemia definition) (K/DOQI definition) Percent with anemia (K/DOQI definition)
KEEP N= 49,694, age; 48,749, race. NHANES N= 9,856. *Sample size less than 30 or coefficient of variation not less than 30%. 25 KEEP: Age 25 KEEP: Age 20 20 25 KEEP: Age 15
Race/ethnicity Race/ethnicity Race/ethnicity
15 20 10 10 155 5 100 0 255 NHANES 99-02 99-02 25 NHANES18-45 White Other 200 18-45 White Other Black Hispanic 46-60 20 NHANES 99-02 Black Hispanic 46-60 61+ 25 15 61+ 18-45 White Other 15 20 10 Black Hispanic 46-60 * 10 * 61+ * * 155 * * * * * * * ** * * 5 * * * * * * * * * * * 100 ** * * *
by age, race/ethnicity, education, & insurance status KEEP N= 49,694, age; 48,749, race. NHANES N= 9,856. *Sample size less than 30 or coefficient of variation not less than 30%.
Chapter 6 «» Anemia and CKD
Percent w noitathw lbim tuhm iaaulm buinm Mean microalbumin Mean microalbumin level (mg/L) level (mg/L) Percent with Percent abnormal with ACR abnormal icm PeitrhPceemrncitcerw rin oicuarrlob uirniauria Mean microalbumin level (mg/L) Percent with abnormal ACRACR
Percent with Percent anemia with (WHO anemia definition) (WHO definition) Percent with anemia (WHO definition)
25 KEEP: Age 25 KEEP: Age 20 20 KEEP: Age 25 15 15 20 10 10 155 5 100 0 255 NHANES 99-02 99-02 25 NHANES18-45 18-45 200 46-60 20 NHANES 61+ 46-60 99-02 25 15 61+ 18-45 15 20 46-60 10 * 10 61+ * 155 * * 5 100 * 0
6.5
60 60 40 60 40 20 40 20 0 20 0 50 0 50 40 40 50 30
WHO definition WHO definition K/DOQI definition K/DOQI definition No Yes WHO definition Yes No K/DOQI definition No
Yes
No No
Yes Yes
No
Yes
No No
Yes Yes
No
Yes
30 40 20 20 30 10 10 200 0 10 25 0 25 20 20 25 15 15 20 10 10 155 5 100 0 5 0
Microalbuminuria & ACR in KEEP participants with anemia (WHO & K/DOQI definitions) KEEP N= 52,317, microalbumin; 47,612, microalbumin level; 43,580, ACR. Positive microalbumin >20mg/L
s81
KEEP NHANES 99-02
11.8
10 5 0
7.4
5.6
2.5
All
CKD
No CKD
All
CKD
No CKD
15
0 20
Percent of participants with anemia
15
K/DOQI anemia
Percent of participants with anemia Percent of participants with anemia
Percent of participants with anemia
anemia & ckd 20 WHO anemia
5
K/DOQI anemia
15 20 10 WHO anemia 155 100 5 0
6.6
K/DOQI anemia KEEP NHANES 99-02
11.8 All 5.6
CKD
No CKD
7.4All
CKD
No CKD
CKD
No CKD
All
5 0 20
K/DOQI anemia
15 10 5
2.5
All
10
CKD
0
No CKD
All
Anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by CKD status KEEP N= 44,723. NHANES N= 10,018, all, 9,712 CKD.
WHO anemia: KEEP
NHANES 99-02 Male Female
15
WHO anemia: KEEP
NHANES 99-02
20
10
Percent of participants with anemia
Percent of participants with anemia
30
5 0
K/DOQI anemia 20 15 10
30
20 0 30
K/DOQI anemia
White Black Other
20
10
5 0
CKD
0
All
CKD
No CKD
All
CKD
No CKD
All
CKD
No CKD
All
CKD
No CKD
6.7
6.8
Anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by CKD status & gender
Anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by CKD status & race
KEEP N= 44,723. NHANES N= 10,018, all; 9,712, CKD.
KEEP N= 43,823. NHANES N= 10,018, all; 9,712, CKD.
30
WHO anemia: KEEP
Percent of participants with anemia
20
10
0 30
K/DOQI anemia
NHANES 99-02
nder WHO and K/DOQI anemia definitions, 17.3 and 12.9% of KEEP participants with CKD are classified as anemic, and female participants are generally most likely to have anemia regardless of CKD status. By race, black participants are most likely to have anemia. In KEEP and NHANES participants with CKD, for example, 26 and 24%, respectively, are anemic using the WHO anemia definition and 19.6 and 11.2% are White classified as anemic when using Black the K/DOQI definition. Other
20
Of KEEP and NHANES participants with WHO or K/DOQI anemia, 77.9 and 81.8% in KEEP are classified as having Stage 3–5 CKD compared to 40.9 and 57.3% in the NHANES population. KEEP participants in the later stages of CKD are most likely to have anemia. Within all stages of CKD, black KEEP participants are the most likely to have anemia. KEEP participants with diabetes are generally the most likely to be classified as anemic, when using the WHO and K/DOQI anemia definitions.
10
s82
0
All
CKD
No CKD
All
National Kidney Foundation «» Kidney Early Evaluation Program «» 2006
CKD
No CKD
WHO anemia:
10
Percent of participants with anemia
20
10
0 30
K/DOQI anemia
20
10
0
All
NHANES: WHO anemia NHANES: WHO anemia NHANES: WHO anemia
.0 13 2: e 0 . g Sta : 1 3 . 0 Stage 1: 46.9 1 3 1: 9.2 e 2Stage : g Stage 2: 12.2 Sta ge 2 Stage 1: 46.9 StaStage 1: 9.2 Stage 1: 9.2 Stage 2: 12.2 Stage 1: 46.9 Stage 2: 12.2 Stages 3-5: 77.9 Stage 3-5: 40.9
Stages 3-5: 77.9 Stages 3-5: 77.9
Stage 3-5: 40.9 Stage 3-5: 40.9
KEEP: K/DOQI anemia
NHANES: K/DOQI anemia
KEEP: K/DOQI anemia KEEP: K/DOQI anemia 1.1 2: 1 ge Sta 11.1 : 1 e 2 11:1.7.1 gStage Sta ge 2: a t S Stage 1: 7.1 Stage 1: 7.1 Stages 3-5: 81.8
NHANES: K/DOQI anemia NHANES: K/DOQI anemia Sta ge 2: 9 . 7* Sta g Stae 2: ge 9.7 2: 9* . 7*
Stage 1: 33.0
Stage 1: 33.0 Stage 1: 33.0 Stages 3-5: 57.3
Stages 3-5: 81.8 Stages 3-5: 81.8
Stages 3-5: 57.3 Stages 3-5: 57.3
80
WHO anemia: KEEP
WHO anemia: KEEP Male 80 WHO anemia: KEEP 80 60
60 60 40
Percent of participants with anemia PercentPercent of participants of participants with anemia with anemia
KEEP: WHO anemia KEEP: WHO anemia KEEP: WHO anemia
Female Male Male Female Female
40 40 20
30
NHANES 99-02
NHANES 99-02 30 NHANES 99-02
080 K/DOQI anemia 0 80 K/DOQI anemia 80 K/DOQI anemia 60 60 60 40
*
20 20 10
*
*
* * *
030 0 30 30 20
*
*
* *
20 20 10
40 40 20
*
*
*
10 10 0
20 200
*
30 20
*
* * ** * * * *1 * Stage 3-5 All Stage 1 Stage 3 All *Stage 0 0 * 2 NCKD Stage 2 Stage 4-5 NCKD * Stage 0 All 0 All Stage 1 Stage 3 Stage 1 Stage 3-5 All Stage 1 2Stage 3 4-5 All NCKD Stage 1 2Stage 3-5 NCKD Stage Stage Stage NCKD Stage 2 Stage 4-5 NCKD Stage 2 10 10 0
20 200
6.9
6.10
Percent distribution of KEEP & NHANES participants with WHO & K/DOQI anemia, by CKD stage
Anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by CKD stage & gender
KEEP N= 2,217, WHO anemia; 1,645, K/DOQI anemia. NHANES N= 1,504. *Sample size less than 30 or coefficient of variation not less than 30%.
KEEP N= 44,723. NHANES N= 10,018, all; 9,712, CKD. *Sample size less than 30 or coefficient of variation not less than 30%.
WHO anemia: KEEP
WHO anemia: KEEP White 80 WHO anemia: KEEP Black 80 60 White Other White Black 60 Hispanic Black 60 40 Other Other Hispanic 40 Hispanic 40 20
50
NHANES 99-02
NHANES 99-02
Percent of participants with anemia PercentPercent of participants of participants with anemia with anemia
5040 NHANES 99-02 50 4030 40 * * 3020 30 * * * * 2010 * 20 * * ** * ** * 20 10 200 0 10 * ** * ** K/DOQI anemia * ** * ** 060 050 0 K/DOQI anemia 0 60 5040 K/DOQI anemia 60 50 40 4030 40 * 40 3020 40 * * * 30 20 * * 2010 * 20 * 20 * 20 ** * * * 10 0 * 0 10 All All Stage 1 Stage 3 Stage ** *1 * * Stage 3-5 * ** Stage 0 NCKD NCKD Stage 2 Stage 4-5 0 * *2 * All Stage 1 Stage 3 All Stage 1 * Stage 3-5 0 0 All Stage 1 Stage 3 All Stage 1 NCKD NCKD Stage 2 Stage 4-5 Stage 2Stage 3-5 6.11 NCKD NCKD Stage 2 Stage 4-5 Stage 2
Anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by CKD stage & race/ethnicity KEEP N= 43,823. NHANES N= 10,018, all. *Sample size less than 30 or coefficient of variation not less than 30%.
Chapter 6 «» Anemia and CKD
80 80 80 60 60 60 40
Percent of participants with anemia PercentPercent of participants of participants with anemia with anemia
80
WHO anemia: KEEP WHO anemia: KEEP Diabetics WHO anemia: KEEP
Non-diabetics Diabetics Diabetics Non-diabetics Non-diabetics
40 40 20 20 200 080 K/DOQI anemia 0 80 K/DOQI anemia 80 K/DOQI anemia 60 60 60 40 40 40 20
30
NHANES 99-02
NHANES 99-02
30 NHANES 99-02 30 20 20 20 10
* *
10 10 0
*
*
*
030 0 30 30 20
* *
* *
20 20 10 10 10 0
* *
*
*
* * * * * * * * * 1 * Stage 3-5 All Stage 1 Stage 3 All Stage * * * Stage 0 NCKD NCKD Stage 2 Stage 4-5 0 2 Stage 1 Stage 3 Stage 1 Stage 3-5 0 All 0 All All Stage 1 Stage 3 All Stage 1 Stage 3-5 NCKD NCKD Stage 2 Stage 4-5 Stage 2 6.12 NCKD NCKD Stage 2 Stage 4-5 Stage 2 20 200
*
Anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by CKD stage & self-reported diabetic status KEEP N= 44,342. NHANES N= 10,013. *Sample size less than 30 or coefficient of variation not less than 30%.
s83
odds of anemia
Odds ratio of anemia
8 WHO anemia KEEP NHANES 99-02 6 4
2 60-<90
≥90
Odds ratio of anemia
6 WHO anemia
4
18-30
(ml/min/1.73m2) 0
≥90
60-<90
6 WHO anemia
2
0
<60
K/DOQI anemia
KEEP NHANES 99-02 K/DOQI anemia
31-45
46-60
≥90
<60
75+
61-75
18-30
31-45
Odds ratio of anemia
K/DOQI anemia
61-75
0
<60
60-<90
KEEP NHANES 99-02
4
2 46-60
K/DOQI anemia
18-30
eGFR (ml/min/1.73m ) 2
75+
31-45
46-60
61-75
75+
18-30
31-45
46-60
61-75
6.13
6.14
Odds ratio of anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by eGFR
Odds ratio of anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by age
KEEP N= 44,075. NHANES N=8,707, participants age 20 and older.
KEEP N= 44,075, NHANES N=8,707, participants age 20 and older.
K/DOQI anemia: Diabetic
KEEP NHANES 99-02
15 10 5 0
6.15
Non-diabetic
White Black Other
White Black Other
Non-diabetic
20 WHO anemia:Diabetic
Odds ratio of anemia
Odds ratio of anemia
20 WHO anemia:Diabetic
75+
Non-diabetic
K/DOQI anemia: Diabetic
Non-diabetic
White Black Other
White Black Other
KEEP NHANES 99-02
15 10
5 Black Other White 0
White Black Other
White Black Other
White Black Other
Odds ratio of anemia (WHO & K/DOQI definitions) in KEEP & NHANES participants, by race & self-reported diabetic status KEEP N= 44,075. NHANES N= 8,707, participants age 20 and older.
he odds of having anemia are greatest in participants with eGFRs of less than 60 ml/min/1.73 m2. In the KEEP population, for example, the odds of anemia in participants with eGFRs of less than 60 ml/min/1.73 m2, are 80% (WHO) and 100% (K/DOQI) higher when compared to those with an eGFR equal to or greater than 90 ml/ min/1.73 m2. KEEP participants age 75 and older are more than two times as likely to have anemia compared to those age 46–60. By either the WHO or K/DOQI anemia
s84
definition, both black diabetic and nondiabetic KEEP participants are 3–5 times more likely to be anemic compared to white non-diabetics. KEEP and NHANES participants age 75 and older are more than twice as likely to be anemic compared to participants age 46–60. Diabetes is a significant risk factor for anemia. Black diabetics, for example, are five to ten times more likely to be anemic compared to white non-diabetics. Participants with eGFRs <60 are 2–4 times more likely to be anemic compared to those with eGFRS of 90+.
National Kidney Foundation «» Kidney Early Evaluation Program «» 2006
WHO anemia
7 6
WHO anemia
5 7 4 6 3 5 2 4
Odds ratio Odds of anemia ratio of anemia
WHO anemia K/DOQI anemia OR CI P-value OR CI P-value Age (ref: 46-60) 18-30 1.18 (1.03-1.34) 0.0147 0.47 (0.38-0.59) <.0001 31-45 1.45 (1.33-1.57) <.0001 0.81 (0.72-0.91) 0.0005 61-75 1.19 (1.10-1.30) <.0001 1.37 (1.25-1.52) <.0001 >75 2.26 (2.02-2.53) <.0001 2.40 (2.11-2.73) <.0001 Male (ref: female) 0.65 (0.61-0.70) <.0001 0.31 (0.28-0.35) <.0001 Smoking & used to smoke 0.93 (0.88-0.99) 0.0243 0.92 (0.85-1.00) 0.0372 Self-reported HTN 1.12 (1.05-1.20) 0.0011 1.26 (1.15-1.37) <.0001 Family history DM 0.99 (0.93-1.06) 0.8233 0.99 (0.91-1.08) 0.7629 Family history EBP 0.98 (0.91-1.06) 0.6815 0.94 (0.85-1.04) 0.2384 BMI 30+ 1.03 (0.96-1.09) 0.4214 1.02 (0.94-1.10) 0.6458 eGFR (ref 90+) <60 1.81 (1.65-1.98) <.0001 2.06 (1.85-2.30) <.0001 60-<90 0.88 (0.82-0.95) 0.0006 0.86 (0.78-0.95) 0.0020 Race & diabetic status (ref: White/NDM) White/DM 2.13 (1.91-2.38) <.0001 2.14 (1.87-2.45) <.0001 Black/NDM 3.32 (3.04-3.62) <.0001 3.15 (2.81-3.53) <.0001 Black/DM 5.04 (4.52-5.62) <.0001 5.57 (4.88-6.36) <.0001 Other/NDM 1.42 (1.26-1.61) <.0001 1.51 (1.28-1.78) <.0001 Other/DM 2.69 (2.33-3.10) <.0001 3.06 (2.57-3.64) <.0001
1 3 0 2
K/DOQI anemia
1 7 0 6
K/DOQI anemia
5 7 4 6 3 5 2 4 1 3 0 2 1 0
Smoking eGFR: 90+ <60 White/DM Black/DM Other/DM SRHTN 60-<90 White/NDM Black/NDM Oth./NDM Smoking eGFR: 90+ <60 White/DM Black/DM Other/DM SRHTN 60-<90 White/NDM Black/NDM Oth./NDM
6.a
6.16
Odds ratio of anemia (WHO & K/DOQI definitions) in KEEP participants, by patient characteristics
Odds ratio of anemia (WHO & K/DOQI definitions) in KEEP participants, by race & risk factor
KEEP N= 44,075.
KEEP N= 44,075.
20 WHO anemia 15 WHO anemia 20 10 15 Odds ratio Odds of anemia ratio of anemia
WHO anemia K/DOQI anemia OR CI P-value OR CI P-value Age (ref: 46-60) 20-30 1.05 (0.70-1.56) 0.814 0.37 (0.23-0.61) 0.000 31-45 1.13 (0.82-1.55) 0.449 0.56 (0.34-0.93) 0.027 61-75 1.17 (0.78-1.76) 0.436 1.16 (0.72-1.88) 0.535 >75 2.02 (1.31-3.12) 0.002 2.29 (1.34-3.93) 0.004 Male (ref: female) 0.39 (0.31-0.48) 0.0001 0.26 (0.18-0.38) 0.0001 Smoking & used to smoke 0.85 (0.69-1.06) 0.146 0.99 (0.72-1.36) 0.949 Self-reported HTN 0.85 (0.66-1.08) 0.179 0.93 (0.63-1.39) 0.728 GFR (ref: 90+) <60 3.24 (2.16-4.87) 0.0001 4.78 (3.02-7.58) 0.0001 60-<90 0.79 (0.58-1.07) 0.127 1.11 (0.69, 1.80) 0.652 Race & diabetic status (ref: White/NDM) White/DM 2.32 (1.47-3.67) 0.001 2.16 (1.32-3.53) 0.003 Black/NDM 5.98 (4.55-7.86) 0.0001 7.08 (5.05-9.91) 0.0001 Black/DM 10.62 (6.26-18.0) 0.0001 10.37 (5.97-18.0) 0.0001 Other/NDM 2.19 (1.51-3.18) 0.0001 3.35 (1.85-6.07) 0.0001 Other/DM 4.24 (2.22-8.12) 0.0001 5.62 (2.33-13.52) 0.0001
5 10 0 5 K/DOQI anemia 20 0 15 K/DOQI anemia 20 10 15 5 10 0 5Smk/used GFR <60 Black/NDM Other/NDM to smoke SR HTN White/DM Black/DM Other/DM 0 Smk/used GFR <60 Black/NDM Other/NDM to smoke SR HTN White/DM Black/DM Other/DM
6.b
6.17
Odds ratio of anemia (WHO & K/DOQI definitions) in NHANES participants, by patient characteristics
Odds ratio of anemia (WHO & K/DOQI definitions) in NHANES participants, by race & risk factor
NHANES N=8,707, participants age 20 and older.
NHANES N= 8,707, participants age 20 and older.
Chapter 6 «» Anemia and CKD
s85
chapter highlights
Figure 6.1 The percentage of KEEP and NHANES participants with anemia increases with age, reaching 20 and 15%, respectively, in participants age 75 and older. Anemia is more prominent in females compared to males—13.2 versus 8.8% in the KEEP population. Figure 6.6 Under WHO and K/DOQI anemia definitions, 17.3 and 12.9% of KEEP participants with CKD are classified as anemic.
Anemia Definitions
WHO Male: hemoglobin <13 g/dl Female: <12g/dl K/DOQI Males: hemoglobin <12g/dl Women age >50: <12g/dl Women age ≤50: <11 g/dl
CKD Definition
If eGFR by K/DOQI MDRD <60 ml/ min/1.73 m2 or eGFR ≥60 ml/min/1.73 m2 and abnormal albumin/creatinine ratio (ACR ≥30mg/g)
Positive Microalbumin >20 mg/L
s86
Figure 6.9 Of KEEP and NHANES participants with WHO or K/DOQI anemia, 77.9 and 81.8% are classified as having Stage 3–5 CKD compared to 40.9 and 57.3% in the NHANES population. Table 6.a The odds of having anemia are greatest in participants with eGFRs of less than 60 ml/min/1.73 m2. In the KEEP population, for example, the odds of anemia in participants with eGFRs of less than 60 ml/min/1.73 m2 are 80–100% higher when compared to those with an eGFR equal to or greater than 90 ml/min/1.73 m2.
CKD Stages
Stage 1: eGFR ≥90, ACR ≥30 mg/g Stage 2: eGFR 60–89, ACR ≥30 mg/g Stage 3: eGFR 30–59 Stage 4: eGFR 15–29 Stage 5: eGFR <15 or dialysis
Abnormal albumin/creatinine ratio (ACR) ACR ≥30 mg/g
Education & insurance
National Kidney Foundation «» Kidney Early Evaluation Program «» 2006