HD Conference 14 Nov

HD Conference
14 November 2023
F1 Pacharapon Sinchairojkul
Patient Profile
ผู้ป่วยหญิงอายุ
62 ปี
สิทธิ์การรักษา จ่าย
ตรงกรมบัญชีกลาง
อาการสำคัญ
อ่อนเพลียมากขึ้น 3
เดือน ตรวจพบโลหิตจาง
Patient
background
Known case BFR 350 DFR Kt/v nPCR
800
2.26 0.77
-ESKD on HD อ, พฤ, ส via Lt.AVF
Na135 K 3(ปี
Ca 2546)
3.5 HCO3 32 2.35 0.94
-HT, DLP Heparin 1500 u
then 500 u/hr
-Sigmoid cancer pT2N1M0 , stage II วินิจฉัย พค 66
มาด้วย hematochezia with significant weight loss
S/P AR c appendectomy 31/5/66
Patho: well-differentiated adenocarcinoma, free margin,
1/11 LN involvement, no vascular invasion
CTWA(8/6/66): patent anastomotic site, no
residual mass, lymph node
Last Follow up 31/10/66: stable, CEA 1.88-1.93 (0-
Hb
Date Hct(%) Ferritin %Tsat MCV RDW Treatment
(g/dL)
1/6/66 10.2 30 86 Encifer 100mg iv q 2wk
25/6/66 7.3 22.1 85
Retic 1.6% LPRC 2u

4/7/66 7.4 22.4 14.6 consult Sx: no delayed
ARC 42,300 postsurgical bleeding
6/7/66 10 30.6 772 24 86 Encifer 100mg iv q 2wk
13/7/66 8.7 27 88
Encifer 100mg iv q 2wk

3/8/66 8.3 26 86 14.3

7/9/66 9 28 871 32 84

2/11/66 8.7 27 819 41 88
Current medication
-Encifer 100 mg iv q 2 week
-Losartan(50) 1x1 o pc
-Manidipine(20) 1x1 o pc
-Atorvastatin(20) 1x1 o pc E
-Ezetimibe(10) 1x1 o pc E
-VitD2(20,000) 1 cap o q 1wk
-Thiamine(100) 1x3 o pc
-Vit B complex 1x3 o pc
Physical
-V/S: T 36 C, Examination
0
BP 126/53 mmHg, P 84/min, RR 16/min,
SpO2 98% , BW 57.3 kg, IDWG 2.8kg
DW 54.5 kg, Ht 148 cm
-GA: Elderly Thai female, mild pallor, no jaundice
-HEENT: mild pale conjunctivae, anicteric sclerae
-CVS: JVP 3cm above sternal angle, pulse full and
regular, PMI at 5th ICS in MCL,
normal S1,S2, no murmur
-RS: trachea in midline, normal equal breath sounds,
no adventitious sound
Physical
Examination
-GI: old surgical scar, no distension, soft,
not tender, normoactive bowel sounds,
no shifting dullness, liver span 11 cm,
no increased splenic dullness
-Ext: no edema, no joint swelling
-Lymphatics: no superficial
lymphadenopathy
-NS: Good consciousness, oriented to
time, place, person, motor gr. V all
Discuss plan
further
management
Complete
blood count
-CBC: Hb 8.7 g/dL, Hct 27%, MCV 88 fL, MCHC 32, RDW 16.6
-WBC 4500/mm3 (N 52%, L 36%), Platelet 214,000/mm3
Iron
study
-Ferritin 819 ,%Tsat 41 ,Serum iron 81 ,TIBC 196
Blood chemistry
Na+ 139 Albumin 3.9

K+ 4.3 Globulin 3.8
Ca2+ 9.34
Cl- 99 TB/DB 0.5/0.2
PO43- 3.5
HCO3- 24
VitD 34 AST 17
iPTH 161 ALT 9
BUN 47
ALP 122
Cr 8.1
The Use of Erythropoiesis-Stimulating Agents
in Patients With CKD and Cancer
ESA treatment in CKD/ESKD with
Cancer
The only FDA-approved indication: Anemia by current myelosuppressive chemotherapy
Incremental risk of ESA

-Thrombotic and stroke risk
-Mortality risk
-worsening hypertension
-Progression of malignancy
(Less likely in some cancer)
Kidney International (2014) 86,
Cancer progression and ESA:
Mechanism
• ESA binding to EpoR on tumor cells
- Increased tumor proliferation and growth
- Decreased apoptosis
- Increased resistance to cancer therapy
• ESA binding to EpoR on monocytes and macrophages

- Resulting immunocompromised state may promote tumor progression
• Altered tissue oxygenation may promote tumor growth

- Increased lymphangiogenesis may lead to lymph node metastasis
Thavarajah S et al .:The Use of Erythropoiesis-Stimulating Agents in Patients With CKD and Cancer: A Clinical Approach: AJKD(2019)
ENHANCE trial
-double-blind placebo-controlled trial
-examined the impact of anemia correction on response to radiotherapy
P: 351 patients (Hb <12 g/dL in women or <13 g/dL in men) with carcinoma of the oral
cavity, oropharynx, hypopharynx, or larynx
I: EPO beta was administered at a dose of 300 IU/kg subcutaneously 3 times weekly
C: placebo
O: The ESA group had increased locoregional progression (relative risk [RR], 1.69;
P = 0.007) and death (RR, 1.39; P = 0.02)
THE LANCET • Vol 362 • October 18, 20

ENHANCE trial
Postop RT
Postop RT in uncompleted resection Primary definitive RT
THE LANCET • Vol 362 • October 18, 20

BEST trial
-double-blind placebo-controlled trial, multicernter study
P: 939 women with metastatic breast cancer (MBC) receiving first-line chemotherapy
I: Epoetin alfa 40,000 U once weekly for 12 months
C: placebo
O: 12-month overall survival was 70% for epoetin alfa and 76% for placebo group(P = 0.01)
76% vs 70%
Leyland-Jones ,et al: Maintaining normal hemoglobin levels with epoeitin alfa in mainly non- anemic patients with metastatic breast cancer receiving first- line chemotherapy: a survival study. J Clin Oncol. 2005;23(25): 5960-5972
TREAT study: T2DM, CKD-ND
-randomized, double-blind, placebo-controlled trial

P: 4038 patients with diabetes, chronic kidney disease, and anemia
I: Darbepoetin alfa to achieve Hb 13 g/dl (N = 2012)
C: placebo (N=2026)
O: post-hoc analysis in cancer subgroup with baseline malignant condition
-Deaths from any cause: 60/188 patients (darbepoetin alfa) ~ 37/160 patients (placebo)
(P = 0.13 by the log-rank test)
-Cancer death: 14/188 patients (darbepoetin alfa) << 1/160 patients (placebo)
(P=0.002 by the log-rank test)
N Engl J Med 2009; 361:2019-2032 DOI: 10.1056/NEJMoa0907845

Current recommendation
ASCO/ASH, ESMO 2010

-ESAs for chemotherapy-induced anemia when Hb < 10 g/dL
-ESAs during active therapy and to be stopped by 1 month postcompletion
-Aim for lower target Hb
-No recommendations for those with underlying CKD and cancer
FDA 2007, 2017

Cautious use of ESAs for those with history of cancer or current malignancy
Use of ESA if chemotherapy-induced anemia undergoing active treatment
Do not continue ESAs beyond 1 mo posttreatment
Suggested avoidance if anticipated cure
KDIGO Anemia Guidelines 2012

-Incorporation of FDA warning
-ESA use with caution if active malignancy or history of malignancy
If Hb > 10 g/dL, ESA not needed
If Hb<10 g/dL, ESA use to avoid Hb<9 g/dL
Thavarajah S et al .:The Use of Erythropoiesis-Stimulating Agents in Patients With CKD and Cancer: A Clinical Approach: AJKD(2019)
Summary
Kidney International (2014) 86,

In this patient
Evaluate other cause of anemia in postoperative phase
-Sx evaluation: no anastomotic leakage, no collection/ hematoma
Evaluation disease and curative aim

-No residual tumor
Find concomitant risk: No thrombosis, No uncontrol hypertension
Discuss benefit and risk with patient and care giver
Administer ESA low dose 2000u x 3 times /wk
Aim Hb reach upper limit at 10 g/dL
APPRISE: Assisting Providers and cancer Patients

with Risk information for the Safe use of ESAs
REMS: risk evaluation and mitigation strategy

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1/6/66 10.2 30 86 Encifer 100mg iv q 2wk

25/6/66 7.3 22.1 85

Retic 1.6% LPRC 2u

6/7/66 10 30.6 772 24 86 Encifer 100mg iv q 2wk

Encifer 100mg iv q 2wk

Encifer 100mg iv q 2wk

Encifer 100mg iv q 2wk

Na+ 139 Albumin 3.9

Incremental risk of ESA

• ESA binding to EpoR on monocytes and macrophages

• Altered tissue oxygenation may promote tumor growth

THE LANCET • Vol 362 • October 18, 20

Postop RT in uncompleted resection Primary definitive RT

THE LANCET • Vol 362 • October 18, 20

-randomized, double-blind, placebo-controlled trial

O: post-hoc analysis in cancer subgroup with baseline malignant condition

N Engl J Med 2009; 361:2019-2032 DOI: 10.1056/NEJMoa0907845

ASCO/ASH, ESMO 2010

FDA 2007, 2017

KDIGO Anemia Guidelines 2012

Kidney International (2014) 86,

Evaluation disease and curative aim

Find concomitant risk: No thrombosis, No uncontrol hypertension

Discuss benefit and risk with patient and care giver

Administer ESA low dose 2000u x 3 times /wk

Aim Hb reach upper limit at 10 g/dL

APPRISE: Assisting Providers and cancer Patients

REMS: risk evaluation and mitigation strategy

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