Role of Anaemia – from CRS to CRAS CRAS definition and epidemiology.
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Transcript of Role of Anaemia – from CRS to CRAS CRAS definition and epidemiology.
Role of Anaemia – from CRS to CRAS
CRAS definition and epidemiology
The First Definition of CRAS
Silverberg proposed the term Cardio-Renal Anaemia Syndrome (CRAS) 10 years ago to reflect that there is an interaction between
renal failure, heart failure and anaemia
Silverberg D et al. Eur J Heart Fail 2002;4(6):681–686
Anaemia
Heartfailure
Renalfailure
The Definition of CRAS Differs Depending on your Viewpoint (1)
Nephrologists
CKDAny degree of
anaemiaAny degree of heart failure
CKD Severe anaemiaSevere
heart failure
Renal failure Severe anaemia Cardiovascular events
Renal failure AnaemiaCardiovascular
disease
CKD Anaemia CHF
The Definition of CRAS Differs Depending on your Viewpoint (2)
Cardiologists
CHFAny degree of
anaemiaAny degree of
renal insufficiency
CHF Severe anaemia Renal failure
Cardiovascular disease
Severe anaemia Renal failure
Cardiovascular disease
Anaemia Renal insufficiency
CHF Anaemia CKD
A Definition of CRAS for 2010
CRAS is a pathophysiological process involving the progressive deterioration of heart and kidney function linked with worsening anaemia
– CRAS is a vicious cycle where worsening of one factor negatively impacts on the other two conditions and itself, resulting in progressive deterioration
CRAS is a combination of heart failure, kidney failure and anaemia
What defines the above factors?
Any degree of heart failure
Any degree of anaemia
Any degree of kidney failure
The Prevalence of CRAS is Dependant upon your Definition of CKD, CHF and of Anaemia
CHF CKD
Anaemia
Anaemia +
CKD
Anaemia +
CHF
CRAS
CHF + CKD
A total of 9,971 patients had a value for Hb reported that was ≤11 g/dL in 18% of men and 23% of women
Cleland JG et al. Eur Heart J 2003;24:442–463
N=5249 men
33% with Hb <12 g/dL
Nu
mb
er
of
pati
en
ts
Hb (g/dL)
500
400
300
200
100
04–4.4
5–5.46–6.4
7–7.4
8–8.4
9–9.4
10–10.4
11–11.4
12–12.4
13–13.4
14–14.4
15–15.4
16–16.4
17–17.4
18–18.4
19–19.4
20–20.4
Hb levels in the EuroHeart Failure Survey Programme
CRAS in US and European HF Surveys
Galvao M et al. J Card Fail 2006;12:100–107; Nieminen MS et al. Eur J Heart Fail 2008;10:140–148
60
50
40
30
20
10
0ADHERE 105,000 patients EuroHF Survey II
Renal failure Anaemia
Pati
en
ts (
%)
Prevalence Data for CRAS are Varied
Anaemia is common in patients with heart failure (HF) –prevalence ranges from 4–55%1
In patients with CHF NYHA functional class IV, the prevalence of anaemia when defined as <12g/dL and ≤11g/dL was 79.1%3 and 14.4%, respectively4
The prevalence of renal impairment plus anaemia (≤11g/dL) in New York heart association (NYHA) functional class IV HF patients is 6.3%4
The prevalence of chronic renal insufficiency (CRI) in new onset HF patients is 8.8%2 and the prevalence of renal insufficiency in acutely decompensated HF patients is 30%5
The prevalence of CHF in endstage renal disease is 63.7%6
1. Lang C & Mancini D. Heart 2007;93:665–671; 2. Ezekowitz J et al. Circulation 2003;107:223–225; 3. Silverberg D et al. J Am Coll Cardiol 2000;35:1737–1744; 4. Cromie N et al. Heart 2002;87:377–378;
5. Fonarow G et al. JAMA 2005;293:572–580; 6. Avorn J et al. Arch Intern Med 2002;162:2002–2006
New-onset HF Patients with both CKD and Anaemia
Population-based cohort of 12,065 patients with new-onset CHF
– Database analysis from 138 acute-care Canadian hospitals
– April 1993–March 2001
– Analysis of prevalence and cause of anaemia
Adapted from Ezekowitz J et al. Circulation 2003;107:223–225
14%3%
6%
77%
CHF + anaemia alone (n=1,696)
CHF + anaemia + CKD (n=387)
CHF + CKD alone (n=674)
CHF alone (n=9,308)
HF, CKD and Anaemia Occur Frequently in the Same Patient
Prospective, single-centre, observational study2
– 955 consecutive patients with HF (LVEF <45%)
– Median follow-up 531 days
– Investigation of the presence of anaemia, and its cause
Adapted from de Silva R et al. Am J Cardiol 2006;98:391–398
CHF + anaemia* alone (n=94)CHF + anaemia* + CKD** (n=211)CHF + CKD** alone (n=307)CHF alone (n=343)
LVEF, left ventricular ejection fraction*Hb <12 g/dL in women, <13 g/dL in men; **eGFR <60 mL/min/1.73 m2
10%
22%
32%
36%
CHF + anaemia* alone (n=304)
CHF + anaemia* + CKD** (n=373)
CHF + CKD** alone (n=583)
CHF alone (n=1393)
14%
11.5%
22%
52.5%
Multivariable analysis of data from the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) Program
– 2,653 patients with NYHA class II–IV
Prevalence of CRAS may be Greater than Current Estimates
“…about half the patients admitted to hospital with a primary diagnosis of CHF…have anaemia…and the great majority will also have CKI (chronic kidney insufficiency)”1
Silverberg et al. noted the majority of CKI patients with anaemia also had CHF2
1. Silverberg DS et al. Semin Nephrol 2006;26:296; 2. Silverberg D et al. Nephrol Dial Transplant 2003;18(suppl 8):viii7–viii12
Prevalence Data for CRAS are Limited
Very few studies have specifically assessed the prevalence of CRAS within the CKD and CHF populations
Exclusion criteria for clinical trials often remove patients with CRAS and so a true prevalence of the disorder is unknown