Background: Chronic kidney disease is a problem that has reached epidemic proportions worldwide. It is expected that the incidence and prevalence will increase in the coming decades impacting cardiovascular morbidity and mortality and the cost to health systems. Worldwide, clinical practice guidelines have been developed for the screening and/or early diagnosis and timely management of complications of chronic kidney disease, based on a rigorous process of systematic review of available evidence. Anemia is a frequent complication and although its pathogenesis is multifactorial, the decrease in the endogenous erythropoietin production at the renal level constitute the primary cause, which is why the current treatment is based on the use of recombinant human erythropoietin available for clinical use since 1989. The optimization of the treatment to achieve and maintain hemoglobin within the target of the recommended ranges continues to be a great challenge for nephrologists, since they influence modifiable variables (iron deficiency, dialysis dose) and non-modifiable variables (sex, age) that affect the capacity of response to treatment with erythropoietin._x000D_ Objectives: to evaluate the quality of clinical practice guidelines on chronic kidney disease, define the convenience of early or late start of erythropoietin for the treatment of anemia in patients on dialysis, and determine if there is a difference according to sex in the doses of erythropoietin needed to maintain recommended hemoglobin levels for hemodialysis patients._x000D_ Methods: we conducted three research studies to tackle each of the objectives specified previously. These were: (1). a study on the quality of the guidelines on chronic kidney disease based on the criteria of the AGREE II instrument; (2). a systematic review with the Cochrane Kidney and Transplant group, following the Cochrane methodology, to evaluate the efficacy and safety of the early or late use of erythropoietin for the treatment of anemia in dialysis patients; and (3). a retrospective cohort study of hemodialysis patients to determine if there are gender differences in the doses of erythropoietin needed to maintain target hemoglobin. Results: 1. Regarding the first study, 13 clinical practice guidelines were found that included the screening and/or early diagnosis of chronic kidney disease; 85% of the guides were “recommended” for use, however, the domains of “applicability” (47.9%) and “stakeholder participation” (58.2%) had the lowest scores in the evaluation, which is considered a negative factor for the “implementation” of the guides. 2. Regarding the Cochrane review, no evidence was found for or against the early or late use of erythropoietin for the management of dialysis patients with anemia. 3. Finally, in regard to the third study, it was found that women require higher doses of erythropoietin than men to maintain the recommended hemoglobin level; in addition, women have four times the risk of using high doses of erythropoietin._x000D_ Conclusions: 1. the majority of clinical practice guidelines of chronic kidney disease can be recommended for use for the primary care and specialized doctor; however in clinical practice the implementation doesn't seem to be effective because there is still an increase in the incidence of chronic kidney disease that is higher than expected. A possible explanation are the findings in the study in which it is reported a “low” or “medium” quality in the domains “stakeholder participation” and “applicability”, domains that are very important for the effective “implementation” of a guideline; 2. there is no available evidence of usefulness in the early or late use of erythropoietin in the dialysis patient with anemia. There is a need then to make quality studies that answer this question; and 3. women on hemodialysis require higher doses of erythropoietin to achieve and maintain the recommended level of hemoglobin so this should be taken into account when establishing dosage, especially in incident patients that have a major morbidity and mortality in the initial months associated with the delay of achieving the recommended target hemoglobin level.
Tamizaje de la enfermedad renal crónica y uso de eritropoyetina para el manejo de la anemia en pacientes en diálisis.
Coronado Daza, J. A. (Author). 13 Dec 2019
Student thesis: Doctoral thesis
Student thesis: Doctoral thesis