2155 (IC14) anaemia

Question 1

What is erythropoietin?

Answer 1

Glycoprotein cytokine produced by kidneys in response to tissue hypoxia

Question 2

Function of erythropoietin

Answer 2

Stimulate erythropoiesis in bone marrow → Increase RBC production

Bind to EPO receptors → activate progenitor cells to differentiate and proliferate to mature RBC

Question 3

2 strategies to improve half life and stability of epoietin

Answer 3

1. Add more N linked groups (Darbepoietin VS Epoietin Alfa and Beta)
2. PEGylation, adding Polyethylene Glycol to epoietin

Question 4

Why do CKD patients have decreased RBC production? (4 points)

Answer 4

1. From decreased production of Erythropoietin by kidney
2. Accumulation of uremic toxins → Inhibit erythropoiesis
3. Bone marrow fibrosis caused by hyperparathyroidism (elevated thyroid hormone PTH from CKD mineral bone disease)
4. CKD patients have nutritional deficiencies

Question 5

Normal and anemic levels of Haemoglobin for male and females

Answer 5

Male
Normal: 13-15g/dL, Anaemia: < 13

Female
Normal: 12-14g/dL, Anaemia: < 12

Question 6

Consequences and Complications of anemia

Answer 6

Decreased O2 delivery to other organs can result in LVH, MI, stroke

Question 7

Target for Hgb, should not exceed how much?

Answer 7

10-11.5g/dL, should not exceed 13

Question 8

Goal TSAT

Answer 8

20-30%

Question 9

Goal Serum Ferritin

Answer 9

200-500 for HD patients, 100-100 for non-HD patients

Question 10

What is TSAT

Answer 10

Transferrin Saturation, measure amount of iron available for delivery to bone marrow

Question 11

What is TSAT equation?

Answer 11

Serum Iron/TIBC x 100%

Question 12

What is serum ferritin?

Answer 12

Indirect measure of iron stores, is an acute phase reactant

Question 13

When to start ESA?

Answer 13

Start ESA when Hbg < 10g/dL

Question 14

Dose titration of ESA? eg. too fast, too slow, Hgb approaching 12, exceed 13?

Answer 14

Hgb should increase 1-2g/dL per month

If Hgb increase < 1g/dL over 4 weeks (too slow), increase frequency

If Hgb increase > 1g/dL over 2 weeks (too fast), increase dosing interval

If Hgb approaching 12, increase ESA dosing interval

If Hgb > 13g/dL, hold EPO until Hgb < 12-12.5, then restart at longer frequency

Too high Hgb → blood is thicker, greater risk of clots

Dose adjust every 2-4 weeks

Question 15

Causes of hyporesponsiveness to ESAs

Answer 15

Iron deficiency / Folate, B12 deficiency
All these needed to make RBC

Hyperparathyroidism

Aluminium toxicity

and many more…

Question 16

Why does iron deficiency occur in CKD patients? (2 points)

Answer 16

1) Malnutrition

2) ESA treatment increases iron demand

Question 17

What are the 2 types of iron deficiency?

Answer 17

Absolute → Low TSAT, Low Ferritin
AKA low iron freely available, low iron stores

Functional → Low TSAT, high Ferritin
AKA low iron freely available, high iron stores
Alot of iron stores not cannot release fast enough to meet demands
May also be due to inflammation causing increase in Ferritin, hence not accurate

Question 18

What are the 2 types of oral iron? What are their relative iron elemental %?

Answer 18

Ferrous gluconate (Sangobion): 12% elemental iron

Iron polymaltose (Maltofer): 100% elemental iron

Question 19

How much iron do non HD patients need?

Answer 19

200mg

Question 20

What is IV iron called and the brand name?

Answer 20

Iron Sucrose (Venofer)

Question 21

What is the dosing of Iron Sucrose?

Answer 21

During each HD session, give Loading dose of 100mg x 10 doses or 200mg x 5 doses = 1g per month

Maintenance dose
100-200mg IV per month

Question 22

Side effects of IV iron

Answer 22

Hypotension, dizziness, dyspnea, syncope, arthritis, back pain, joint pain

Anaphylactoid reaction

Iron overload

Cause hepatic, pancreatic, cardiac dysfunction
Increase risk of infection

Withhold IV iron during acute infection or switch to oral iron

Oxidative stress

Question 23

When is transfusion appropriate?

Answer 23

For patients with acute blood loss and severe symptomatic anaemia
Symptoms eg. pale, short of breath

Question 24

Risks during transfusion

Answer 24

Impair bone marrow RBC synthesis
Volume overload
Iron overload
Infection eg. hepatitis, HIV

Question 25

Who should avoid doing transfusion?

Answer 25

Avoid transfusion for patients who are candidates for kidney transplant!
Risk immune reaction against blood
Eventually, body might reject kidney
Give higher doses of ESAs, not transfusion

Question 26

DO not start ESAs when patient has

Answer 26

(absolute) active cancer and patient is receiving treatment with curative intent
(relative) history of stroke
history of malignancy