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Clinical practice guidelines for anemia in chronic kidney disease: Problems and solutions. A position statement from Kidney Disease: Improving Global Outcomes (KDIGO)

Department of Nephrology and Dialysis, Ospedale A. Manzoni, Lecco, Italy.
Kidney International (Impact Factor: 8.56). 08/2008; 74(10):1237-40. DOI: 10.1038/ki.2008.299
Source: PubMed

ABSTRACT

The development of clinical practice guidelines for the treatment of anemia in chronic kidney disease has been instrumental in identifying and reducing variations in the use of erythropoiesis-stimulating agents and iron replacement. Challenges to the effectiveness and safety of recommendations made in these guidelines were magnified when recent clinical trials showed no benefit or harm with respect to cardiovascular outcomes in subjects randomized to higher target hemoglobin levels. To address these concerns, Kidney Disease: Improving Global Outcomes (KDIGO) convened an international conference to examine the problems and shortcomings of existing anemia guidelines, which are a prime example of duplication of efforts to derive recommendations from a limited evidence base. The meeting was attended by representatives of the major guideline developing organizations, who agreed to avoid future duplicative efforts and to save resources in generating a common evidence report, whose recommendations could then be prioritized and implemented locally. This is a report to the international nephrology community of the recommendations for and timeline of the next anemia guidelines. It has been reviewed by the conference participants and approved as a position statement by the KDIGO Board of Directors.

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Available from: Rowan G Walker, Dec 30, 2013
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    • "The achieved results are similar for the three countries, although the best results are encountered for Portugal. Guidelines for anemia management suggest to keep Hb level between 10 and 13 g/dl and most recently between 10 and 12 g/dl, thus, aiming to the middle of the desired range, a deviation of 1g/dl is permitted [25] [26]. We thus calculated the percentage of errors lower than 1 g/dl for Portugal, Italy and Spain, finding success percentages of 93%, 91% and 90%, respectively. "
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    ABSTRACT: Chronic Kidney Disease (CKD) anemia is one of the main common comorbidities in patients undergoing End Stage Renal Disease (ESRD). Iron supplement and especially Erythropoiesis Stimulating Agents (ESA) have become the treatment of choice for that anemia. However, it is very complicated to find an adequate treatment for every patient in each particular situation since dosage guidelines are based on average behaviors, and thus, they do not take into account the particular response to those drugs by different patients, although that response may vary enormously from one patient to another and even for the same patient in different stages of the anemia. This work proposes an advance with respect to previous works that have faced this problem using different methodologies (Machine Learning (ML), among others), since the diversity of the CKD population has been explicitly taken into account in order to produce a general and reliable model for the prediction of ESA/Iron therapy response. Furthermore, the ML model makes use of both human physiology and drug pharmacology to produce a model that outperforms previous approaches, yielding Mean Absolute Errors (MAE) of the Hemoglobin (Hb) prediction around or lower than 0.6g/dl in the three countries analyzed in the study, namely, Spain, Italy and Portugal. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Full-text · Article · Mar 2015 · Computers in Biology and Medicine
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    • "The achieved results are similar for the three countries, although the best results are encountered for Portugal. Guidelines for anemia management suggest to keep Hb level between 10 and 13 g/dl and most recently between 10 and 12 g/dl, thus, aiming to the middle of the desired range, a deviation of 1g/dl is permitted [25] [26]. We thus calculated the percentage of errors lower than 1 g/dl for Portugal, Italy and Spain, finding success percentages of 93%, 91% and 90%, respectively. "
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    ABSTRACT: Objective: Anemia is a frequent comorbidity in hemodialysis patients that can be successfully treated by administering erythropoiesis-stimulating agents (ESAs). ESAs dosing is currently based on clinical protocols that often do not account for the high inter- and intra-individual variability in the patient's response. As a result, the hemoglobin level of some patients oscillates around the target range, which is associated with multiple risks and side-effects. This work proposes a methodology based on reinforcement learning (RL) to optimize ESA therapy. Methods: RL is a data-driven approach for solving sequential decision-making problems that are formulated as Markov decision processes (MDPs). Computing optimal drug administration strategies for chronic diseases is a sequential decision-making problem in which the goal is to find the best sequence of drug doses. MDPs are particularly suitable for modeling these problems due to their ability to capture the uncertainty associated with the outcome of the treatment and the stochastic nature of the underlying process. The RL algorithm employed in the proposed methodology is fitted Q iteration, which stands out for its ability to make an efficient use of data. Results: The experiments reported here are based on a computational model that describes the effect of ESAs on the hemoglobin level. The performance of the proposed method is evaluated and compared with the well-known Q-learning algorithm and with a standard protocol. Simulation results show that the performance of Q-learning is substantially lower than FQI and the protocol. When comparing FQI and the protocol, FQI achieves an increment of 27.6% in the proportion of patients that are within the targeted range of hemoglobin during the period of treatment. In addition, the quantity of drug needed is reduced by 5.13%, which indicates a more efficient use of ESAs. Conclusion: Although prospective validation is required, promising results demonstrate the potential of RL to become an alternative to current protocols.
    Full-text · Article · Sep 2014 · Artificial Intelligence in Medicine
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    • "Therefore , in theory , increasing reticulocytes with erythropoietin replace - ment could increase the risk for vaso - occlusive crisis ( Yasin et al , 2003 ) . In non - SCD subjects , published guidelines suggest balancing the risks and benefits of erythropoietin replacement by setting a haemoglobin target level of >11 g / dl but <13 g / dl ( Locatelli et al , 2008 ) . In SCD , the target haemoglobin level needs to be substantially lower , since hyper - viscosity may occur with haemoglobin levels >10 g / dl ( Lottenberg & Hassell , 2005 ) . "
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    ABSTRACT: In sickle cell disease (SCD), vigorous reticulocytosis is required to partially compensate for chronic hemolytic anaemia. Consequently, early renal damage, insufficient to cause azotemia but sufficient to cause erythropoietin deficiency and chronic relative reticulocytopenia (chRR), could have severe clinical consequences. chRR was defined as reticulocytes <250×10(9) /l despite haemoglobin <9 g/dl on ≥ two occasions ≥4 weeks apart. The influence of multiple variables including chRR on time from first clinic visit to death was evaluated in 306 SCD patients. In univariate analyses, fetal haemoglobin, indices of renal damage (serum creatinine, proteinuria), chRR and age, were associated with rate of death. In multivariate analysis, only age and chRR (Hazard ratio 3·6, 95% CI 2·049-6·327, P<0·0001) were significant, underlining that chRR could be an early and important clinical consequence of renal damage. Even in chRR patients with normal serum creatinine levels, low haemoglobin and low reticulocyte counts were associated with low erythropoietin levels. In the general population, evaluation of erythropoietin levels is prompted by the combination of anaemia and abnormal serum creatinine. In SCD patients, this standard approach can miss a substantial risk factor for early death. chRR could be a practical and important criterion for diagnosis of erythropoietin deficiency in SCD.
    Full-text · Article · Mar 2011 · British Journal of Haematology
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