23 - CKD 2 Anemia Flashcards

1
Q

KDOQI
Definition for CKD Anemia

A

Hemoglobin (Hb)

Males
Hb < 13.5 g/dL

Females
Hb < 12 g/dL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

S/Sx of CKD Anemia

A

TachyCardia

  • *PALE
  • **Conjuctiva / palms / nail beds

Decreased MENTAL ACUITY / neurological sx

Worsening of LVH

Systolic Murmor

Fatigue / Dizziness / SOB / Palpitations / Chest Pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Pathogenesis
CKD Anemia

A

Decreased Survival of RBCs / Bleeding

Erythropoietin (EPO)
normocytic & normochromic

Acute / Chronic Inflammatory Conditions

SEVERE HYPERparathyroidism

Microlytic Anemia = Iron deficiency

Macrolytic Anemia = Folic acid / vitb12 deficiency

aluminum toxicity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

ESA
Use in CKD Anemia

A

Erythropoiesis Stimulating Agents

  • *Exogenous ESA** is needed because:
  • *Kidney is NO LONGER forming EPO** to stimulate RBC production in bone marrow

Glycoproteins with same biologic fxn as EPO
Reduced need for TRANSFUSION

SC or IV injections

Weight Based Dosing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

When can we Initiate ESA Therapy?
KDOQI CPG

A

To start ESA, have to be below:
Hb < 11-12 g/dL

Goal is:
11 - 12 g/dL, not >13

we do NOT want a quick rise, due to overshooting
rate of rise:
1-2 over 1 month

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

When can we Initiate ESA Therapy?
FDA

A

To start ESA, have to be below:
Hb < 10 g/dL
Goal Followed

Goal is:
< 11 g/dL

we do NOT want a quick rise, due to overshooting
rate of rise:
< 1 g/dL over 2 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

ESA
ADR’s / Contraindications

A

BLACK BOX WARNING
use the lowest dose sufficient to reduce the need for RBC transfusion
Increased risk of: MI / stroke / VTE / VE / Tumor progression

  • *Contraindications**
  • *Uncontrolled HTN** / Pure Red Cell Aplasia
  • Precautions: (can still start)*
  • *Stroke / MI / thromboembolism / Seizures**
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

ESA
Dose Adjustments

Do NOT dose adjust more frequently than:

Response typically seen:
2-6 weeks

Medicare payment based on:
Hb < 12 g/dL

A

dose is DIFFERENT for CANCER patients

Monitor Hb:
Weekly / BI-weekly / Monthly

If hemoglobin rises quickly
= >1g/dL in 2 weeks -> may reduce ESA dose by 25%+
if >11g/dL –> reduce or hold dose

If Hb does NOT respond by
>1g/dL in 4 weeks –> increase dose by 25%
response is typically seen over 12 weeks, if no response unlikely to improve

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Darbepoetin
ESA - Aranesp

Half Life + Dose

A

Half-Life
21hr IV // 46hr SC

Dose
0.45 mcg/kg qweekor 0.75mcg/kg q2weeks
For non-dialysis:
0.45 mcg/kg q4 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Methoxy Polyethylene Glycol-Epoetin Beta
ESA - Mircera

Half Life + Dose

A

Half-Life
134 - 139 H

Dose
0.6 mcg/kg q2 weeks
until Hb stable then double dose qmonth

ONCE EVERY 2 WEEKS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Epoetin Alfa
ESA - Epogen / ProCrit

Half Life + Dose

A

Half-Life
8.5hr IV // 24hr SC

Dose
50-100 units/kg TIW

THREE TIMES A WEEK

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

ESA Dose Conversions

A

Epoetin Alfa = 3x a Week
so, converting to Darbepoetin = Weekly
need to convert accordingly

Also:
Micera is every 2 weeks or every 1 month

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Causes for ESA RESISTANCE

A
**_IRON DEFICIENCY_**
#1 cause, should be **iron replete b4 starting ESA**

Inflammation / Infxn
CKD = stage of chronic inflammation

HYPERparathyroidism

Folic Acid + VitB12 Deficiency

Chronic Blood loss / Malnutrtion / Alminum toxicity / Inadequate Dialysis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Cancer + ESA Considerations

A

INCREASED RISK
of cancer spreading / tumor increase / recurrance

WAIT 5 YEARS to be CANCER FREE
b4 starting ESA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Hepcidin Function

A

Peptide made in liver that REGULATES:
Intestinal FE absorption / Recycling / Mobilization
from hepatic stores

CONTRIBUTES TO ANEMIA in CKD (BAD)
when inflammation / Infection present

  • *Hepcidin –> binds to Ferroportin** in macrophages
  • INHIBITS Fe Availability*

basis for most:
“anemia of chronic disease”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

TSAT

A

Percentage Transferrin Saturation

TSAT = ( Serum Fe / TIBC ) x 100

Goal is 20-50% for all stages

TIBC > 200
for an accurate TSAT

17
Q

Serum Iron

A

Serum Fe
Concentration of Fe bound to Transferrin
affected by inflammation & infection

Diurnal Effect

18
Q

TIBC

A

TIBC = Total Iron Binding Capacity

Capacity of the blood
to BIND iron WITHOUT
Transferrin

Should be >200 to get an accurate TSAT

19
Q

KDIGO
Iron Goals

TSAT / Ferritin

A

Measure iron status q3months during ESA therapy

STILL ON TRIAL
if we want to increase Hb +/- decrease dose of ESA if on ESA

TSAT
< 30%

Ferritin
< 500

20
Q

KDOQI
Iron Goals

TSAT / Ferritin

A

TSAT
> 20% for all stages

Ferritin
> 200 ng/mL HemoDialysis

> 100 ng/mL non-dialysis or peritoneal

21
Q

Ferritin

A
  • *Amount of Fe** STORED in the:
  • *liver / spleen / bone marrow cells**
  • *SPECIFIC for Fe DEFICIENCY**
  • WHEN LOW*

High Ferritin =/= does NOT mean Iron EXCESS
since it is an Acute Phase reactant (elevated in infxn/inflmation)

Hemodialysis CKD > 200 ng/mL
non HD CKD > 100 ng/mL
200-2000 = iron + inflmattion

22
Q

Iron Deficiency Anemia

A

#1 Cause of Anemia Worldwide

PRIMARY CAUSE OF ESA RESISTANCE
if not getting desired respnse from ESAs

Deficiency is dependent on:

  • *Increased Demand / hematopoiesis
  • increased loss/decreased intake or absorption***
23
Q

Oral Iron

A

TAKE ON EMPTY STOMACH

200mg of ELEMENTAL Fe QD
divide into several doses daily

Start small –> titrate up slowly

ADR:
Fecal Discoloration / NVD / constipation

Treat for 3-6 months

24
Q

Ferric Citrate
Auryxia

A

PHOSPHORUS BINDER** & **IRON SUPPLEMENT

Shown to:

  • *Improve TSAT** + Ferritin Levels
  • can lead to a decrease IRON use*

FDA Approved for:
Iron Deficiency ANEMIA in CKD non-dialysis patients

1g TID w/ meals
max 12g/day

25
**Oral Iron** **DRUG INTERACTIONS**
*_DECREASED absorption of IRON_* **PPI / H2 Blockers / Cholestyramine Antacids / Calcium / PHOS Binders Tetracycline / Doxycycline** **_AFFECTED by IRON --\> 2 hours_** **Levothyroxine Fluoroquinolones / Mycophenolate** Tetracycline / doxycycline
26
**IV Iron** **Indication / Treatment**
Given when ***PO canNOT be given*** **malabsorption / blood loss / DIALYSIS PATIENTS** Dialysis already **very *IRON DEFICIENT*** PO can NOT meed the demands **Bolus Treatments (1gm)** --\> **reach TSAT levels** then periodic maintenance doses **_Ferric Fe3+ available in IV formulations_** ***_DO NOT GIVE DURING ACTIVE INFECTIONS_***
27
**Which IV IRON** **can NOT be given during DIALYSIS?**
**_FERRIC CARBOXYMALTOSE_** injectafer ## Footnote **ONLY FOR *NON-DIALYSIS***
28
**Which IV IRON** **Requires a TEST DOSE?**
**_IRON DEXTRAN_** due to **anaphylaxis**, also **BBW** **2 Brands that are NOT interchangable** **_Ferumoxytol_** also has **anaphylactic reactions** also needs to be given as a **diluted product**
29
**Which IV IRON** **MUST BE DILUTED?**
* *_FERUMOXYTOL_** * *BBW**, can also have **anaphylaxis** **IVPB --\> infused over 15 minutes** monitor for 30 min post infusion / 1 hour of dialysis b4 admin **Contrainidicated with H/O Allergic RXN to ANY IV IRON** **MRI caution**
30
**Which IV IRON** **Is ADDED TO DIALYSIS SOLUTION?**
**_FERRIC PYROPHOSPHATE CITRATE_** Triferic, **HD only** **Delivers 5-7mg fe with EACH treatment** (dialysis removes the same amount) ADR: **HypoTension / HA / muscle spasms / peripeheral edema**
31
**Which IV Iron** **Has DELAYED ADRs 1-2 days post dose?** **Arthralgia / backache / chills / dizziness** **Fever / HA / malaise / myalgia / N/V**
**_IRON DEXTRAN_** IM / IVP / IVPB diluted **Requires TEST DOSE** (anaphylaxis) **BBW** **2 brand products are NOT interchangable**
32
**MACROlytic Anemia**
**VITAMIN B12 + FOLIC Acid deficiency** causes **Immature LARGE RBCs** * *_MCV \> 100 fL_** * inadequate INTAKE + decreased ABSORPTION* **Low b12 \<150 pg/mL** + **low folic acid \<7 nmol/L** * *MMA is specific for B12 deficiency** * may also measure homocysteine*
33
**MACROcytic Anemia** **TREATMENT**
* *_Vitamin B12_** * *PO: 1-2mg of cobalamin QD** * *IM: 1000mcg qd f1week -\> weekly 1 month --\> qmonth** * *_Folic Acid_** * *1mg QD** **Reticulocytosis begins within 1st week** VV **bone marrow becomes normoblastin in several days** VVV **Hb rises and normalizes in 1-2 months**
34
**TRANSFUSIONS**
**LAST LINE** given in **acute situations / cardiac instability / when you can NOT alleviate blood loss quickly** ***_many RISKS_*** **bacterial / paracitic infections Iron OVERload / CITRATE toxicity** **_Increase ALLOANTIGEN SENSITIZATION_** prolong time to **recieve transplant / risk of reejection**