Chronic Kidney Disease Anemia Flashcards
Vitamin B12 and Folic Acid Role
Final maturation of RBC
Lack of these causes Macrocytic Anemia (Large RBC with low hemoglobin)
ESA
- Goals
- Dose Increase/Decrease
Goal is to rise Hgb by 10 after 2-4 weeks, Ferritin 100-500, TSAT 20-40%
If increase greater than 10 after 2 weeks / 20 after 4 weeks (Excessive)
- Decrease dose by 25-50%
If decrease greater than 10 after 4 weeks (Inadequate)
- Increase dose by 25%
At what stage of CKD does anemia surpass 50% prevelnance
Stage 4 and 5 of CKD
Oral Iron
- Drug Interactions
Drugs that lower iron absorption
- Calcium Carbonate
- Antacids (PPIs, H2 Antagonists)
- Cholestyramine
- Sodium Bicarbonate
Iron lowers absorption of drugs
- Levothyroxine
- Bisphosphonates
- Levodopa/Methyldopa
- Quinolone/Tetracycline Antibiotics
Erythropoietin Function
Produced by kidneys
Decreased O2 –> Increases EPO production –> Stimulates Bone Marrow –> Increases RBC production
Iron Deficiency
- Causes
Functional Iron Deficiency
- Elevated Hepcidin
- ESA Treatment
Absolute Iron Deficiency
- Blood Loss
- Lack of Absorption from GI
Total Iron Binding Capacity
Indirect measure of the iron binding capacity of serum transferrin
When to start Iron Therapy
When we want to increase Hemoglobin
TSAT < 30% and Ferritin < 500
CKD Anemia Causes
EPO deficiency
Iron deficiency
Nutrition deficiency
Blood loss
Reduced RBC lifespan
Inflammation
Infection
Hematologic Disease
Hyperparathyroidism
Hemolysis
Oral Iron
- Considerations
Ferrous Fumerate, Ferrous Sulfate, Ferrous Gluconate
- Needs acid in stomach to be absorbed
- Best absorption on empty stomach or with Vitamin C
Polysaccharide Iron
- Take with or without food
- Does not need acid to be absorbed
Heme Iron
- More bioavailable
- Take with or without food
- Does not need acid to be absorbed
ESA
- Monitoring
Initiation: Monthly
Maintenance
- Dialysis: Monthly
- Non-Dialysis: Every 3 months
Iron should be monitored every 3 months (TSAT and Ferritin)
Symptoms and Sings of CKD Anemia
Fatigue
Lethargy
Dyspnea
Tachycardia
Glossitis
Pallor
When to start ESA Therapy
Have already addressed all other causes of anemia (iron deficiency)
Dialysis: Hgb 90-100 (Prevent from dipping below 90)
Non-Dialysis CKD: Hgb less than 100
Do not use to maintain Hgb greater than 115
Oral Iron
- Adverse Effects
Nausea
Vomiting
Dyspepsia
Constipation
Diarrhea
Dark Stools
Transferrin Saturation
Amount of circulating iron that is available for use in the bone marrow for RBC production
Transferrin
Iron transport protein (Transports iron from gut to other tissues)
Serum Iron
Amount of iron in circulation that is bound to transferrin
Ferritin
Main iron storage protein
Hepcidin
Regulates iron by absorbing it
Increased production of Hepcidin during inflammation and infection
Iron Deficiency
- Definition
Functional Iron Deficiency (TSAT < 20%)
- Good Iron Storage (Normal Ferritin)
- Poor Iron Mobilization
–> Less total available iron
Absolute Iron Deficiency (TSAT < 20%)
- Poor Iron Storage (Low Ferritin)
- Impaired Iron Delivery to Bone Marrow
ESA
- Adverse Effects
- Hypertension
- Increased risk of vascular clotting
- Increased risk of stroke, thromboembolism, and cancer mortality
- Pure Red Cell Aplasia
- ESA Resistance
Iron Function
Synthesis of hemoglobin
Synthesis of RBC
Target Iron Levels
Ferritin greater than 100
TSAT 20-40%
Relation between Anemia and CKD
CKD results in reduced erythropoietin synthesis
- Reduced RBC production and anemia
CKD results in iron deficiency
Anemia can result from inflammatory conditions
Oral vs IV Iron
Use IV Iron if patient can not tolerate GI side effects of Oral Iron
Use IV Iron if patient is not meeting TSAT and Ferritin thresholds
