Anemia of CKD

Question 1

Why do we use Ca binders for PO4?

Answer 1

Ca is cheap
Because you take the binder with a meal, most of it will stay in your GI tract and be excreted, not absorbed systemically

Question 2

Lower levels of Hb in CKD patients are associated with what things

Answer 2

CV risk
CHF
LV hypertrophy
Mortality
Progression of renal dysfunction

Question 3

What kind of anemia is in CKD?

Answer 3

Normocytic, normochromic, hypoproliferative

Normal cells, just fewer of them!

Question 4

3 reasons why CKD patients are anemic

Answer 4

1. EPO deficiency/lack of responsiveness to hypoxia
2. Iron abnormalities (loss, impaired absorption, functional)
3. Shortened RBC survival

Question 5

How does EPO work?

Answer 5

It inhibits the apoptosis of erythroblasts

Question 6

HIFs

Answer 6

Hypoxia inducible factors
Always around, but when you have normal O2 content you break them down
If you’re hypoxic, they’re stabilized and promote transcription of EPO
Now there are drugs that do this

Question 7

Why is EPO decreased in CKD patients?

Answer 7

EPO is made in peritubular capillary cells (fewer healthy cells = less EPO)
Cells also stop responding to EPO
Not as much, and doesnt work well

Question 8

What is

1. Transferrin
2. Ferritin

Answer 8

1. Iron form for use

2. Storage form of iron

Question 9

Iron loss in CKD/dialysis patients

Answer 9

Frequent blood sampling
Uremic bleeding/coagulopathy
Hemodialysis circuit losses
Procedures
GI loss

Question 10

Hepcidin function

Answer 10

Inflammation leads to high hepcidin levels
Reduces gut reabsorption of Fe
Hepcidin blocks Fe transporters (locks ferritin stored in liver, spleen, and macrophages)

Question 11

3 mechanisms for decreased RBC survival

Answer 11

Decreased EPO effect
Chronic inflammation
Uremic milieu

Question 12

What is the main problem with CKD patients getting blood transfusions?

Answer 12

Transfusion is a potentially sensitizing event

Makes it harder to find a kidney match if they need a transplant

Question 13

What is the problem with IV Fe?

Answer 13

It bypasses normal regulatory systems because it is not taken up through the gut

Question 14

Why is there an infection risk with iron?

Answer 14

Iron is a key nutrient for bacteria
We sequester iron in storage tissues during infections
Fe impairs host immune response by decreasing function of leukocytes
Iron should be held in patients with active infection

Question 15

ESA

Answer 15

EPO stimulating agent

Question 16

Why do ESAs increase cancer?

Answer 16

It is an anti-apoptotic hormone

Use should be avoided in active malignancy