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Managing renal anaemia in the 21st century
European Journal of Internal Medicine 13 (2002) 409–411 www.elsevier.com / locate / ejim
Editorial
Managing renal anaemia in the 21st century Marie Chowrimootoo*, David B.G. Oliveira Renal Unit, Perimeter Road, St. George’ s Hospital, Blackshaw Road, Tooting, London, SW17 0 QT, UK Received 4 July 2002; accepted 25 July 2002
Effective treatment of anaemia in patients with renal failure with intravenous iron and epoetin (recombinant human erythropoietin) therapy improves survival, decreases morbidity and promotes a better quality of life [1–3]. Since the initial administration to humans [4], progress has been achieved with extraordinary rapidity. There now exists a plethora of research and literature advocating the effectiveness of anaemia management in renal patients with cardiovascular disease, diabetes mellitus, chronic obstructive pulmonary disease, cancer and renal transplants [5–8]. Traditionally, the medical team has carried out management of anaemia with minimal input from nurses. However, in the early 1990s, nephrologists in the UK endorsed the idea that senior renal nurses could effectively manage this area of treatment. With financial sponsorship from pharmaceutical companies dealing in the anaemia field, anaemia co-ordinators / sisters, now more nationally known as Anaemia Nurse Specialists, were employed. They became instrumental in developing an agreed system of written protocols, upon which practice in their local units should be based, in an attempt to meet the standards and guidelines set by three main advisory committees [9–11]. As new evidence has become available, these guidelines have been updated, with new and higher targets being set in anaemia management. The Kidney Disease Outcomes Quality Initiatives and The European Best Practice Guidelines now advocate a minimum target haemoglobin of 11 g / dl to be achieved by 85% of patients with renal failure. The Renal Association maintains a minimum haemoglobin of 10 g / dl as their goal. *Corresponding author. Tel.: 144-20-8725-2466, fax: 144-20-87252068. E-mail address: [email protected] (M. Chowrimootoo).
In spite of identified discordance between clinical practice and the guidelines [12], significant improvement has been achieved in anaemia management, as highlighted by the fourth annual report of the UK Renal Registry [13]. In patients on haemodialysis, 79% had a haemoglobin greater than 10 g / dl in 2000, as compared to 72% in 1999 and 69% in 1998. The corresponding figures for patients on peritoneal dialysis were 86, 80 and 78%. The report from the UK Renal Registry also highlights the fact that there is increasing evidence of significantly different approaches to the use of iron replacement in the setting of epoetin therapy in various centres. The use of iron (particularly intravenous iron preparations) is important because it enhances haematological responses and allows an effective reduction in epoetin dosage, leading to improved cost-effectiveness [14]. Fig. 1 is one of the algorithms used at St George’s Hospital illustrating the place of iron therapy in the effective management of renal anaemia. So far, the Anaemia Nurse Specialists in post have worked independently and autonomously, albeit as part of the multidisciplinary team in their local unit. This independence in practice has, to some extent, limited the sharing of information amongst the various renal units and has given rise to a slow dissemination of evidence-based practice. In an attempt to provide a platform for discussing, sharing and, as appropriate, standardising best nursing practice for patients with anaemia, an Anaemia Nurse Specialist Association has been set up [15]. Since its establishment, the role of the Anaemia Nurse Specialist has evolved tremendously; more are becoming nurse prescribers for iron and epoetin therapies under the Patient Group Directives of their local trust. This system is a specific written instruction for the supply and administration of named medicines in an identified clinical set up. It is drawn up locally by doctors, pharmacists and other
0953-6205 / 02 / $ – see front matter 2002 Elsevier Science B.V. All rights reserved. PII: S0953-6205( 02 )00128-0
410
M. Chowrimootoo, D.B.G. Oliveira / European Journal of Internal Medicine 13 (2002) 409–411
Fig. 1. Condensed algorithm for iron management.
appropriate professionals and endorsed by relevant professional advisory committees. Health minister Mr. John Hutton announced on 17 September 2001 the establishment of nurse consultant posts; the government plans to use the knowledge and skills of the most experienced and expert practitioners to help modernise and reshape services for the benefit of NHS patients. It would seem a logical development for the Anaemia Nurse Specialist to progress to this level in due course [16]. The change in the management of renal anaemia over the last 1–2 decades has shown that advances in basic molecular biology are not enough. The translation of such advances into effective patient care requires increased resources, both for the drug itself and, perhaps more
importantly, for the development of specialised skills for its optimum use. The resulting evolution of the Anaemia Nurse Specialist role serves as a model for the benefits to patients of multiprofessional working in the health service.
References [1] Silverberg DS et al. Erythropoeitin for the anaemia of heart failure. J Am Col Cardiol 2000;35(7):1737–44. [2] Fink JC et al. Use of erythropoeitin before the initiation of dialysis and its impact on mortality. Am J Kidney Dis 2001;37(2):348–55. [3] 2nd European Epoetin Symposium Optimizing Anaemia therapy in CRF. Crete, April 17–19, 1998. [4] Winearls CG, Oliver DO, Pippard MJ, Reid C, Downing MR, Cotes PM. Effect of human Erythropoietin derived from recombinant DNA
M. Chowrimootoo, D.B.G. Oliveira / European Journal of Internal Medicine 13 (2002) 409–411
[5]
[6] [7]
[8] [9]
on the anaemia of patients maintained by chronic haemodialysis. Lancet 1986;2:1175–8. Van C et al. Should anaemia in subtypes of CRF patients be managed differently? Nephron Dial Tranplant 1999;14(suppl 2):37– 45. Eckardt K-U. The CREATE trial—building the evidence. Nephrol Dial Transplant 2001;16(suppl 2):16–8. Dammacco F, Castoldi G, Rodjer S. Efficacy of epoetin alfa in the treatment of anaemia of multiple myeloma. Br J Haematol 2001;113:172–9. Libretto SE et al. Improvement in quality of life for cancer patients treated with epoetin alfa. Eur J Cancer 2001;10:183–91. The Renal Association and Royal College of Physicians Standards Document Treatment Adults and Children with Renal Failure 1995; 1997; 2001.
411
[10] The Dialysis Outcomes Quality Initiative (DOQI) 1997. The Kidney Disease Outcomes Quality Initiatives (K / DOQI) 2001. [11] The European Best Practice Guidelines for the management of anaemia in patients with Chronic Renal Failure, 1999. [12] 3rd International Symposium Anaemia Management and Research 5–8 April, Paris, France, 2001. [13] Ansell D, Feest T. The 4th Annual Report. The UK Renal Registry, 2001. [14] Macdougall I. Past, present and future of iron. In: 1st National Intravenous Iron Study Day Suppl. October, 1998. [15] Chowrimootoo M, Bennett L, Thompson B, Jenkins K. Shaping an Independent Future. June 2002-ANSA website: www.ansa-uk.org. [16] Department of Health (DoH). South East Regional Office. Press release. www.dch.gov.uk / stheast
Editorial
Managing renal anaemia in the 21st century Marie Chowrimootoo*, David B.G. Oliveira Renal Unit, Perimeter Road, St. George’ s Hospital, Blackshaw Road, Tooting, London, SW17 0 QT, UK Received 4 July 2002; accepted 25 July 2002
Effective treatment of anaemia in patients with renal failure with intravenous iron and epoetin (recombinant human erythropoietin) therapy improves survival, decreases morbidity and promotes a better quality of life [1–3]. Since the initial administration to humans [4], progress has been achieved with extraordinary rapidity. There now exists a plethora of research and literature advocating the effectiveness of anaemia management in renal patients with cardiovascular disease, diabetes mellitus, chronic obstructive pulmonary disease, cancer and renal transplants [5–8]. Traditionally, the medical team has carried out management of anaemia with minimal input from nurses. However, in the early 1990s, nephrologists in the UK endorsed the idea that senior renal nurses could effectively manage this area of treatment. With financial sponsorship from pharmaceutical companies dealing in the anaemia field, anaemia co-ordinators / sisters, now more nationally known as Anaemia Nurse Specialists, were employed. They became instrumental in developing an agreed system of written protocols, upon which practice in their local units should be based, in an attempt to meet the standards and guidelines set by three main advisory committees [9–11]. As new evidence has become available, these guidelines have been updated, with new and higher targets being set in anaemia management. The Kidney Disease Outcomes Quality Initiatives and The European Best Practice Guidelines now advocate a minimum target haemoglobin of 11 g / dl to be achieved by 85% of patients with renal failure. The Renal Association maintains a minimum haemoglobin of 10 g / dl as their goal. *Corresponding author. Tel.: 144-20-8725-2466, fax: 144-20-87252068. E-mail address: [email protected] (M. Chowrimootoo).
In spite of identified discordance between clinical practice and the guidelines [12], significant improvement has been achieved in anaemia management, as highlighted by the fourth annual report of the UK Renal Registry [13]. In patients on haemodialysis, 79% had a haemoglobin greater than 10 g / dl in 2000, as compared to 72% in 1999 and 69% in 1998. The corresponding figures for patients on peritoneal dialysis were 86, 80 and 78%. The report from the UK Renal Registry also highlights the fact that there is increasing evidence of significantly different approaches to the use of iron replacement in the setting of epoetin therapy in various centres. The use of iron (particularly intravenous iron preparations) is important because it enhances haematological responses and allows an effective reduction in epoetin dosage, leading to improved cost-effectiveness [14]. Fig. 1 is one of the algorithms used at St George’s Hospital illustrating the place of iron therapy in the effective management of renal anaemia. So far, the Anaemia Nurse Specialists in post have worked independently and autonomously, albeit as part of the multidisciplinary team in their local unit. This independence in practice has, to some extent, limited the sharing of information amongst the various renal units and has given rise to a slow dissemination of evidence-based practice. In an attempt to provide a platform for discussing, sharing and, as appropriate, standardising best nursing practice for patients with anaemia, an Anaemia Nurse Specialist Association has been set up [15]. Since its establishment, the role of the Anaemia Nurse Specialist has evolved tremendously; more are becoming nurse prescribers for iron and epoetin therapies under the Patient Group Directives of their local trust. This system is a specific written instruction for the supply and administration of named medicines in an identified clinical set up. It is drawn up locally by doctors, pharmacists and other
0953-6205 / 02 / $ – see front matter 2002 Elsevier Science B.V. All rights reserved. PII: S0953-6205( 02 )00128-0
410
M. Chowrimootoo, D.B.G. Oliveira / European Journal of Internal Medicine 13 (2002) 409–411
Fig. 1. Condensed algorithm for iron management.
appropriate professionals and endorsed by relevant professional advisory committees. Health minister Mr. John Hutton announced on 17 September 2001 the establishment of nurse consultant posts; the government plans to use the knowledge and skills of the most experienced and expert practitioners to help modernise and reshape services for the benefit of NHS patients. It would seem a logical development for the Anaemia Nurse Specialist to progress to this level in due course [16]. The change in the management of renal anaemia over the last 1–2 decades has shown that advances in basic molecular biology are not enough. The translation of such advances into effective patient care requires increased resources, both for the drug itself and, perhaps more
importantly, for the development of specialised skills for its optimum use. The resulting evolution of the Anaemia Nurse Specialist role serves as a model for the benefits to patients of multiprofessional working in the health service.
References [1] Silverberg DS et al. Erythropoeitin for the anaemia of heart failure. J Am Col Cardiol 2000;35(7):1737–44. [2] Fink JC et al. Use of erythropoeitin before the initiation of dialysis and its impact on mortality. Am J Kidney Dis 2001;37(2):348–55. [3] 2nd European Epoetin Symposium Optimizing Anaemia therapy in CRF. Crete, April 17–19, 1998. [4] Winearls CG, Oliver DO, Pippard MJ, Reid C, Downing MR, Cotes PM. Effect of human Erythropoietin derived from recombinant DNA
M. Chowrimootoo, D.B.G. Oliveira / European Journal of Internal Medicine 13 (2002) 409–411
[5]
[6] [7]
[8] [9]
on the anaemia of patients maintained by chronic haemodialysis. Lancet 1986;2:1175–8. Van C et al. Should anaemia in subtypes of CRF patients be managed differently? Nephron Dial Tranplant 1999;14(suppl 2):37– 45. Eckardt K-U. The CREATE trial—building the evidence. Nephrol Dial Transplant 2001;16(suppl 2):16–8. Dammacco F, Castoldi G, Rodjer S. Efficacy of epoetin alfa in the treatment of anaemia of multiple myeloma. Br J Haematol 2001;113:172–9. Libretto SE et al. Improvement in quality of life for cancer patients treated with epoetin alfa. Eur J Cancer 2001;10:183–91. The Renal Association and Royal College of Physicians Standards Document Treatment Adults and Children with Renal Failure 1995; 1997; 2001.
411
[10] The Dialysis Outcomes Quality Initiative (DOQI) 1997. The Kidney Disease Outcomes Quality Initiatives (K / DOQI) 2001. [11] The European Best Practice Guidelines for the management of anaemia in patients with Chronic Renal Failure, 1999. [12] 3rd International Symposium Anaemia Management and Research 5–8 April, Paris, France, 2001. [13] Ansell D, Feest T. The 4th Annual Report. The UK Renal Registry, 2001. [14] Macdougall I. Past, present and future of iron. In: 1st National Intravenous Iron Study Day Suppl. October, 1998. [15] Chowrimootoo M, Bennett L, Thompson B, Jenkins K. Shaping an Independent Future. June 2002-ANSA website: www.ansa-uk.org. [16] Department of Health (DoH). South East Regional Office. Press release. www.dch.gov.uk / stheast