Dukkipati Ram, Kalantar-Zadeh Kamyar
Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA.
Nephrol News Issues. 2007 Jan;21(1):34-8.
The new National Kidney Foundation's Kidney Disease Outcome Quality Initiative clinical practice guidelines for anemia management in chronic kidney disease include several important modifications to the previous recommendations. These changes may have major implications in clinical practice and outcome of the chronic kidney disease patient population. Among the important guideline modifications are the elimination of the upper thresholds for hemoglobin (12 g/dL), transferrin saturation ratio (TSAT, v 50%) and ferritin (800 ng/ml). There are, however, additional recommendations pertaining to anemia management when hemoglobin is above 13 g/dL or serum ferritin above 500 ng/ml. The KDOQI anemia working group explains that the upper ferritin level of 500 ng/ml is not a stopping point for IV iron administration, but adds that decisions regarding IV iron administration should weigh erythropoietin responsiveness, hemoglobin and transferrin saturation level, and the patient's clinical status.The selected upper ferritin level of 500 ng/ml lacks adequate scientific evidence in the CKD population. Approximately half of all maintenance hemodialysis patients in the United States may have a serum ferritin above 500 ng/ml. Serum ferritin in 500-1,200 ng/ml range is not associated with increased death risk in hemodialysis patients if controlled for the confounding effect of malnutrition and inflammation. Given the lack of support from the literature, any attempt to contemplate an upper limit for serum ferritin would be arbitrary, and would not serve to improve the quality of treatment in the CKD population.
美国国家肾脏基金会新发布的《慢性肾脏病患者贫血管理临床实践指南：改善全球肾脏病预后组织（KDIGO）》对先前的建议进行了多项重要修订。这些变化可能对慢性肾脏病患者群体的临床实践和治疗结果产生重大影响。重要的指南修订内容包括取消血红蛋白（12g/dL）、转铁蛋白饱和度（TSAT，>50%）和铁蛋白（800ng/ml）的上限阈值。然而，对于血红蛋白高于13g/dL或血清铁蛋白高于500ng/ml时的贫血管理，还有其他建议。KDIGO贫血工作组解释说，铁蛋白水平上限500ng/ml并非静脉注射铁剂的停止点，但补充说，关于静脉注射铁剂的决策应权衡促红细胞生成素反应性、血红蛋白和转铁蛋白饱和度水平以及患者的临床状况。选定的铁蛋白水平上限500ng/ml在慢性肾脏病患者群体中缺乏充分的科学依据。在美国，约一半的维持性血液透析患者血清铁蛋白可能高于500ng/ml。如果控制了营养不良和炎症的混杂效应，血清铁蛋白在500 - 1200ng/ml范围内与血液透析患者死亡风险增加无关。鉴于文献中缺乏支持，任何设定血清铁蛋白上限的尝试都是武断的，且无助于提高慢性肾脏病患者群体的治疗质量。
