臨牀透析 Vol.33 No.2(4-1)


特集名 CKD貧血ガイドライン―二度の改訂を巡って
題名 Clinical Question(1)腎性貧血治療の開始基準とすべきHb値はいくつか?
発刊年月 2017年 02月
著者 満生 浩司 福岡赤十字病院腎臓内科
著者 平方 秀樹 福岡腎臓内科クリニック
【 要旨 】 わが国においては2004年に血液透析(HD)患者を対象として腎性貧血治療ガイドラインが作成され,その後,保存期慢性腎不全(ND)患者,腹膜透析(PD)患者も対象に組み入れ,2008年,次いで2015年と改訂されてきた.その間世界的には,正常ヘモグロビン(Hb)値を目指して高用量の赤血球造血刺激因子製剤(ESA)を使用する風潮から一転して,Hb値10g/dL以上ではESAは投与すべきではないという極端な方向転換となった.しかしわが国では影響を受けることなく,本邦のエビデンスを基にして堅実な治療開始基準と目標Hb値が提唱され続けてきた.治療開始基準とは,それ以下のHb値が持続することで生命予後や腎予後にとって不利益となる値と判断される.これまでの研究報告の集積からはND患者ではHb値11.0g/dL未満,HD患者では,血液濃縮やわが国独特の採血条件を鑑みHb値10g/dL未満と考えられる.PD患者に関してはきわめて報告に乏しいが,体液量の変動が少ないことからND患者に準ずるものと判断される.ただし,ESA投与開始に際しては事前に鉄欠乏や尿毒症など他の要因を十分に検索するべきである.
Theme Guideline for CKD-related anemia -- looking back twice's revision
Title Suitable Hb levels for initiating renal anemia treatment
Author Koji Mitsuiki Nephrology and Dialysis Center, Japanese Red Cross Fukuoka Hospital
Author Hideki Hirakata Fukuoka Renal Clinic
[ Summary ] The Japanese Society for Dialysis Therapy (JSDT) has presented revised clinical guidelines for anemia treatment for CKD patients, pre-dialysis, hemodialysis (HD) and peritoneal dialysis (PD), in 2004, 2008 and 2015. After the publication of four large clinical studies conducted in the US and Europe, the Normal-Hematocrit Trial, CREATE, CHOIR and TREAT, high doses of erythropoiesis-stimulating agent (ESA) aiming to achieve near normal levels of hemoglobin (Hb) have been prohibited due to "cardiotoxicity". The KDIGO has lowered suggested target Hb levels during ESA treatment to 10 g/dL and set iron administration as a first-line therapy for the ESA-naïve patients. However, they did not clearly demonstrate the Hb levels for starting ESA.
In Japan, the situation is somewhat different. We have never experienced the achievement of near normal levels of Hb or any apparent cardiotoxicity from ESAs. Although the safety issue related to ESA use has not been fully elucidated, it should be given to patients for whom a sustained-low Hb with sufficient iron levels is expected to be harmful.
The timing for starting ESA is usually assessed by examination Hb levels. However, there is no consensus concerning critical levels of Hb when it is left untreated. From a clinical point of view, it is reasonable to start ESA when Hb levels fall below 10 to 11 g/dL. Target levels should be maintained for several months after confirming efficient iron status. However, we are not sure whether there is any difference between the Hb levels of ESA in non-dialysis CKD patients, PD patients or HD patients. In HD patients, we should be cautious of Hb fluctuations induced by HD procedures.
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