Anemia and CKD

Question 1

Causes of anemia

Answer 1

• Decreased production of erythropoietin (EPO) in the kidney
• Uremia: shortened RBC lifespan
• RBCs destroyed during hemodialysis

Question 2

Signs and Symptoms

Answer 2

• Pallor
• Cold extremities
• Tachycardia
• Poor exercise tolerance
• Weakness
• Angina
• Lowered energy. alertness
• Left ventricular hypertrophy
• Depression

Question 3

Normal Ranges for Hemoglobin

Answer 3

a) Men 14.5-18g/dL

b) Women 12-16g/dL

Question 4

General Approach to Treatment

Answer 4

-Hgb < 13g/dL (males)
or < 12g/dL (females)
-If Hgb increases by greater than 1g/dL in 2wks decrease dose by 25%
-If Hgb decreases by greater than 1g/dL increase the dose by 25%
-Goal: keep Hgb > 10g/dL to avoid ESA therapy

Question 5

Oral Iron Preparations

Answer 5

-200mg elemental iron/day

Question 6

Ferrous gluconate 325mg

Answer 6

36mg (12%)

Question 7

Ferrous sulfate 325mg

Answer 7

65mg (20%)

Question 8

Ferrous fumarate 300mg

Answer 8

99mg (33%)

Question 9

Adverse Effects of Oral Iron Preparations

Answer 9

• GI symptoms
• Constipation/diarrhea
• Dark stools

Question 10

Drug interactions

Answer 10

• Food
• Antacids
• Drugs that increase pH (PPIs, H2 antagonists)

Question 11

Adverse effects of IV iron

Answer 11

• Anaphylactic reaction (iron dextran is the worst)
• Hypotension
• Iron overload (ferritin > 500)
• Avoid administering during active systemic infections

Question 12

Monitoring Parameters for Iron therapy

Answer 12

• Fe status q3mo
• TSAT > 30% q3mo
• Ferritin 500 q3mo
• Hgb q2wk

Question 13

Erythropoietic Stimulating Agents (ESA)

Answer 13

• Same biological effects as endogenous EPO

- Increases Hgb synthesis

Question 14

Half lives of ESA therapy

Answer 14

SC t1/2&raquo_space;> IV t1/2

Question 15

When to extra cautious starting ESA

Answer 15

• Active/history of malignancy

- History of stroke

Question 16

When to start ESA

Answer 16

• CKD nondialysis, Hgb < 10g/dL

- CKD dialysis, start when Hgb 9 to 10 g/dL

Question 17

Monitoring ESA

Answer 17

• Monitor Hgb q1wk when initiating/adjusting therapy, until stable
• Hgb increases by > 1g/dL in 2 weeks decrease dose by 25%
• Hgb does not increase by > 1g/dL in 4 weeks, increase doe by 25%
• After 12 weeks, if still not at goal, d/c medication
• Highly unlikely that your patient will see benefit at this point

Question 18

Causes of ESA resistance

Answer 18

• Iron deficiency
• Folic acid/ B12 deficiencies
• Aluminium intoxication
• Compliance
• PRCA

Question 19

Pure Red Cell Aplasia (PRCA)

Answer 19

• Develop neutralizing antibodies to EPO
• Loss of response to ESA therapy
• Rapid drop is Hgb
• Management: d/c ESA agent, give corticosteroids and cyclosporine/cyclophosphamide
• May also give blood transfusions

Question 20

Adverse effects of ESAs

Answer 20

• Hypertension
• Headaches
• PRCA
• Stroke (Hgb > 13g/dL)

Question 21

ESA Hgb Goals

Answer 21

• Hgb 10 to 11.5

- Hgb > 13g/dL = increased risk of stroke and mortality

Question 22

Iron Dextran

Answer 22

• IV iron supplement

- Highest risk for anaphylaxis of IV iron options