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NNH Clinical Protocol

ESKD Anemia Manager

ESA dose-adjustment calculator for ESKD patients on Aranesp (darbepoetin alfa) or Mircera (methoxy PEG-epoetin beta). Enter the current and prior hemoglobin values, current dose, and frequency to project a 28-day Hb trajectory and recommend a new dose level.

📚 KDIGO 2012 Anemia in CKD📄 Aranesp & Mircera prescribing information⚠️ For NNH clinical staff only

Step 1

Enter hemoglobin trend and current dose

Provide the most recent and prior hemoglobin values with their draw dates, choose the patient’s current ESA, and select the dose (and frequency for Aranesp; Mircera is dosed every 4 weeks).

Recommendation

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Recalculate with new values

Clinical decision support, not a substitute for clinical judgment. This tool supports ESKD patients receiving Aranesp (darbepoetin alfa) or Mircera (methoxy PEG-epoetin beta). The dose-adjustment matrix is institution-specific. Mircera comes in 9 dose strengths only, so some level changes may map to the same Mircera dose; the tool flags these. Verify the recommended dose against the patient’s clinical context, iron studies, and recent transfusions before prescribing. Hold ESA for Hb ≥ 11.5 g/dL and discuss with physician for Hb < 8.0 g/dL or Hb ≥ 12.0 g/dL.

Reference

Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. KDIGO Clinical Practice Guideline for Anemia in Chronic Kidney Disease. Kidney Int Suppl. 2012;2(4):279–335.

Aranesp (darbepoetin alfa) and Mircera (methoxy PEG-epoetin beta) [prescribing information]. Aranesp—Amgen Inc., Thousand Oaks, CA. Mircera—Vifor (International) Inc.

Hemoglobin trajectory matrix

Columns: current Hb (g/dL). Rows: projected 28-day ΔHb (g/dL). Each cell is the dose-change code applied to the patient’s current Nesp Level. Boundaries: ≥ lower AND < upper.

28-day ΔHb ↓ / Current Hb →	6.0–8.0	8.0–8.8	8.8–9.5	9.5–10.0	10.0–10.5	10.5–11.0	11.0–11.5	11.5–12.0	12.0–12.5	12.5–20.0
> +2.0	I1	NC	NC	D1	D2	D3	H	H	MD	MD
+1.5 to +2.0	I2	I1	NC	NC	D1	D2	H	H	MD	MD
+1.0 to +1.5	I3	I2	I1	NC	D1	D2	H	H	MD	MD
+0.5 to +1.0	I3	I2	I1	NC	NC	NC	H	H	MD	MD
−0.5 to +0.5	I3	I2	I1	I1	NC	NC	H	H	MD	MD
−1.0 to −0.5	I3	I2	I2	I1	NC	NC	H	H	MD	MD
−1.5 to −1.0	I3	I3	I2	I2	I1	NC	H	H	MD	MD
−2.0 to −1.5	MD	I3	I3	I2	I1	I1	H	H	MD	MD
< −2.0	MD	I3	I3	I3	I2	I1	H	H	MD	MD

Code legend

Each code maps to a Nesp-Level adjustment applied to the patient’s current dose level.

Code	Action
I1 / I2 / I3	Increase 1, 2, or 3 dose levels
NC	No change — continue current dose
D1 / D2 / D3	Decrease 1, 2, or 3 dose levels
H	Hold ESA (Hb 11.0–12.0 g/dL)
MD	Discuss with physician (Hb < 8.0 or ≥ 12.0 g/dL, or extreme rate of change)

Aranesp ↔ Mircera level mapping

Equivalence of Nesp Levels to Aranesp dose options and the closest Mircera dose. Levels 3 and 17 extend the range below and above the original Aranesp table to accommodate the Mircera 30 mcg and 360 mcg endpoints. Cells flagged as same as L± indicate Mircera dose collapses where adjacent levels share a strength.

Level	Aranesp options	Mircera (q4wk)
3	Mircera-only level	30 mcg
4	25 mcg q5wk	30 mcg (same as L3)
5	25 mcg q4wk · 25 mcg q6wk · 40 mcg q6wk	50 mcg
6	40 mcg q5wk · 25 mcg q3wk	50 mcg (same as L5)
7	40 mcg q4wk · 60 mcg q6wk	75 mcg
8	60 mcg q5wk · 25 mcg q2wk	100 mcg
9	40 mcg q3wk	100 mcg (same as L8)
10	Mircera-only level	120 mcg
11	100 mcg q6wk	120 mcg (same as L10)
12	40 mcg q2wk · 60 mcg q3wk · 100 mcg q5wk	150 mcg
13	100 mcg q4wk · 150 mcg q6wk	200 mcg
14	60 mcg q2wk · 150 mcg q5wk · 100 mcg q3wk · 200 mcg q6wk	250 mcg
15	150 mcg q4wk	250 mcg (same as L14)
16	200 mcg q5wk	250 mcg (same as L14)
17	Mircera-only level	360 mcg

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ESKD Anemia Manager

Enter hemoglobin trend and current dose

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Reference

Hemoglobin trajectory matrix

Code legend

Aranesp ↔ Mircera level mapping

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