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PDAT3 > 23 - CKD 2 Anemia > Flashcards

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

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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

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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

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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

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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

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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

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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**
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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

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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

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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

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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

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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

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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

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14
Q

Cancer + ESA Considerations

A

INCREASED RISK
of cancer spreading / tumor increase / recurrance

WAIT 5 YEARS to be CANCER FREE
b4 starting ESA

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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”

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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 WITHOUTTransferrin

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
Q

Oral Iron

DRUG INTERACTIONS

A

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
Q

IV Iron

Indication / Treatment

A

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
Q

Which IV IRON

can NOT be given during DIALYSIS?

A

FERRIC CARBOXYMALTOSE
injectafer

ONLY FOR NON-DIALYSIS

28
Q

Which IV IRON

Requires a TEST DOSE?

A

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
Q

Which IV IRON

MUST BE DILUTED?

A
  • *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
Q

Which IV IRON

Is ADDED TO DIALYSIS SOLUTION?

A

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
Q

Which IV Iron

Has DELAYED ADRs 1-2 days post dose?

Arthralgia / backache / chills / dizziness

Fever / HA / malaise / myalgia / N/V

A

IRON DEXTRAN
IM / IVP / IVPB diluted

Requires TEST DOSE (anaphylaxis) BBW

2 brand products are NOT interchangable

32
Q

MACROlytic Anemia

A

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
Q

MACROcytic Anemia

TREATMENT

A
  • *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
Q

TRANSFUSIONS

A

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

PDAT3 (23 decks)

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