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anemia Flashcards

1
Q

how is anemia in CKD defined?

A

HGB < 13 g/dL for males
HGB < 12 g/dL for females

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2
Q

what are the goals of therapy for anemia of CKD?

A
  1. increase O2 carrying capacity
  2. improve QOL
  3. prevent/alleviate symptoms and complications of anemia
  4. decrease need for blood transfusions
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3
Q

when does anemia begin to develop?

A

as GFR declines < 45 ml/min/1.73m^2

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4
Q

what are some baseline labs to assess in anemia?

A
  1. HGB
  2. serum iron
  3. serum ferritin
  4. transferrin saturation (Tsat)
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5
Q

what is ferritin?

A

the storage form of iron

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6
Q

what is transferrin saturation?

A

reflects the functional iron available for immediate erythropoesis

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7
Q

hepcidin MOA

A

inhibits ferroportin channel that absorbs Fe to be used

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8
Q

do CKD patients have high or low hepcidin and what is the effect?

A

high hepcidin -> hepcidin is excreted by the kidneys so it accumulates in CKD patients
causes iron deficiency since ferroportin stops working due to lots of hepcidin

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9
Q

what is the most common cause of erythropoietin resistance?

A

iron deficiency

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10
Q

how often should the iron panel be monitored?

A

every 3 months in an ESRD patient and anyone receiving EPO for anemia

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11
Q

what is the therapeutic response to iron?

A
  1. increase in reticulocyte count within 7-14 days
  2. increase in HGB and HCT within 3-4 weeks
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12
Q

what must be done prior to initiating an ESA (EPO stimulating agent)?

A

must correct iron deficiency FIRST

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13
Q

what are the goals of therapy for anemia in CKD?

A

Tsat > 30%
Serum Ferritin > 500 ng/mL

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14
Q

when and why should IV iron be held?

A

Tsat > 50% or Ferritin > 1200 ng/mL
due to risk of iron overload

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15
Q

how often should HGB and HCT be checked once ESA therapy is initiated?

A

weekly during therapy

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16
Q

how often should Tsat and serum ferritin be checked?

A

every 3 months

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17
Q

what are some disadvantages of oral iron therapy?

A
  • poor absorption
  • GI complications: nausea, constipation
  • poor adherence (<50%)
  • slow replenishment of iron stores
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18
Q

what is an advantage to oral iron therapy?

A

inexpensive

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19
Q

what are some advantages of parenteral iron therapy?

A
  • better absorption
  • rapid replenishment of iron stores
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20
Q

what are some advantages of parenteral iron therapy?

A
  • better absorption
  • rapid replenishment of iron stores
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21
Q

what are some adverse effects of oral iron therapy?

A
  • GI: nausea, cramping, constipation
  • dark stool
  • MANY DDIs (e.g. calcium carbonate, antacids)
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22
Q

what are some adverse effects of IV iron therapy?

A
  • dyspnea/wheezing, itching, myalgias
  • hypotension, flushing, edema
  • chest pain, cardiac arrest
  • injection site reaction, anaphylactoid and anaphylactic reactions
  • INFECTION!!
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23
Q

when should we AVOID giving IV iron?

A

in patients with active systemic infection

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24
Q

traditional target oral iron dosing

A

target 200 mg of elemental iron/ day in divided doses
ex: ferrous sulfate 325 mg PO TID

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25
Q

ferrous sulfate

A

tablet: 325 mg (65) or 195 mg (39) 20% elemental iron

26
Q

ferric citrate

A

tablet: 210 mg (210) 100% elemental iron!

27
Q

oral iron DDIs

A

drugs that decrease iron absorption:
- Al, Mg, and Ca containing antacids
- tetracyclines
- H2 antagonists
- PPIs
- cholestyramine
oral iron NEEDS gastric acid to be absorbed!
object drugs affected by iron
- fluoroquinolones
- levothyroxine
- tetracyclines
- mycophenolate
- methyldopa
- levodopa
separate administration by ~ 2 hrs!

28
Q

IV iron formulations

A

ferric gluconate
iron sucrose

29
Q

IV therapy clinical pearls

A
  • IV iron is the preferred therapy in dialysis patients
  • in NON-dialysis patients: a 1-3 month trial of oral iron can be used
    -> can convert to IV if no response > 3 months
30
Q

what are the goals of iron therapy in CKD?

A

Tsat ≥ 30% (limit of 50%)
Serum ferritin ≥ 500 ng/mL (limit of 1200 ng/mL)

31
Q

how often should routine monitoring of Tsat and serum ferritin be done?

A

at least every 3 months

32
Q

epoetin alfa brand name

A

Epogen

33
Q

dosing of epoetin alfa

A

either 3 times a week IV OR once weekly SubQ (preferable due to cost saving)

34
Q

darbepoetin alfa brand name

A

Aranesp

35
Q

dosing of darbepoetin alfa

A

once a week or every 2 weeks (IV or SubQ)

36
Q

methoxy polyethylene glycol epoetin beta brand name

A

Mircera

37
Q

dosing of methoxy polyethylene glycol epoetin beta

A

every 2-4 weeks

38
Q

which is the longest acting ESA?

A

methoxy polyethylene glycol epoetin beta
- can be given up to once a month!

39
Q

MOA of methoxy polyethylene glycol epoetin beta

A

continuous erythropoietin receptor agonist

40
Q

epoetin alfa epbx brand name

A

Retacrit

41
Q

dosing of epoetin alfa epbx

A

3 times a week IV OR once weekly SubQ

42
Q

which ESA is the cheapest?

A

epoetin alfa epbx
-> is a biosimilar of epoetin alfa

43
Q

FDA initiation guideline for ESAs and Hemoglobin targets

A

initiation of ESA: if < 10 g/dL (ESRD)
target HGB: 10-11 avoid transfusions

44
Q

is it normal to give ESA and NOT see any changes in HGB and HCT?

A

YES -> wait and watch, don’t do anything

45
Q

what is the goal change in HGB when starting ESAs?

A

1-2 g/dL/month

46
Q

when should we dose adjust ESAs after initiation?

A

4 weeks (steady state)

47
Q

when should we reduce the ESA dose by ≥ 25%?

A

if patient’s HGB approaches 11 g/dL or if HGB increases > 1g/dL in 2 weeks or less!

48
Q

when should we increase the ESA dose by 25%?

A

if patient’s HGB is below target after 4 weeks of treatment

49
Q

when to hold ESA dose in ND-CKD patients?

A

when HGB > 10

50
Q

when to hold ESA dose in D-CKD patients?

A

when HGB > 11 (11-12; APPROACHING 12 is when you want to hold)

51
Q

ESA hyporesponsiveness

A
  1. no increase in HGB after first month of appropriately dosed ESA
  2. Two ESA dose increases after stable period to maintain HGB
52
Q

ESA resistance

A

failure to achieve a target HGB at a dose of > 500 units/kg/week (5x starting dose)

53
Q

Causes of ESA Resistance

A
  1. IRON DEFICIENCY!!
  2. ACEIs
  3. Hyperparathyroidism
  4. Aluminum toxicity
  5. Folate and/or Vitamin B12 deficiency
  6. Infection*
  7. Malignancy*
  8. Trauma*
  9. Inflammation*
    *decrease bone marrow responsiveness to EPO
54
Q

ESA Adverse Effects

A

HTN (dose-dependent)
Hypercoagulability -> increased risk of thrombosis (DVT, PE, MI, CVA, etc.)
Hypersensitivity rxns
PRBCA: Pure Red Blood Cell Aplasia
Headache, fatigue, edema
Progression of malignancy

55
Q

BBW for ESAs in CKD

A

greater risk of death, serious adverse cardiovascular reactions, and stroke when administered ESAs to target a HGB level > 11 g/dL

56
Q

ESA Monitoring Parameters (initial phase -> maintenance phase)

A

HCT/HGB: 2x a week -> 1-2x a month
BP: 3x a week -> 3x a week
Ferritin: monthly -> quarterly
TSat: monthly -> quarterly
CBC, BUN/Cr, K, Phos: 2x a month -> 1x a month
Reticulocytes: 1x a week -> quarterly

57
Q

ESA Clinical Pearls

A
  • these agents do NOT decrease mortality
  • can be administered IV or SubQ (IV preferred in dialysis and SubQhas longer duration of effect and saves costs)
  • DO NOT USE IF: active malignancy, high risk of CVA, and HGB > 11 g/dL
58
Q

when are PRBCs given?

A

packed red blood cells are given when severe anemia occurs (HGB < 7 g/dL)
-> rapid correction of O2 carrying capacity

59
Q

every 1 unit of PRBC causes what effect on HGB?

A

a 1 g/dL increase in HGB

60
Q

1 unit of PRBC contains how much elemental iron?

A

~ 200 mg

61
Q

at are some risks of blood transfusions?

A
  1. transfusion-related acute lung injury
  2. hypervolemia
  3. hypocalcemia
  4. hypersensitivity rxn
  5. immune activation (bad for kidney transplant candidates)
62
Q

Vitamin Supplementation in Dialysis

A

supplement water-soluble vitamins (B, C, and folic acid)

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