Chronic Kidney Disease Anemia

Question 1

Vitamin B12 and Folic Acid Role

Answer 1

Final maturation of RBC

Lack of these causes Macrocytic Anemia (Large RBC with low hemoglobin)

Question 2

ESA
- Goals
- Dose Increase/Decrease

Answer 2

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%

Question 3

At what stage of CKD does anemia surpass 50% prevelnance

Answer 3

Stage 4 and 5 of CKD

Question 4

Oral Iron
- Drug Interactions

Answer 4

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

Question 5

Erythropoietin Function

Answer 5

Produced by kidneys

Decreased O2 –> Increases EPO production –> Stimulates Bone Marrow –> Increases RBC production

Question 6

Iron Deficiency
- Causes

Answer 6

Functional Iron Deficiency
- Elevated Hepcidin
- ESA Treatment

Absolute Iron Deficiency
- Blood Loss
- Lack of Absorption from GI

Question 7

Total Iron Binding Capacity

Answer 7

Indirect measure of the iron binding capacity of serum transferrin

Question 8

When to start Iron Therapy

Answer 8

When we want to increase Hemoglobin

TSAT < 30% and Ferritin < 500

Question 9

CKD Anemia Causes

Answer 9

EPO deficiency
Iron deficiency
Nutrition deficiency

Blood loss
Reduced RBC lifespan
Inflammation
Infection

Hematologic Disease
Hyperparathyroidism
Hemolysis

Question 10

Oral Iron
- Considerations

Answer 10

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

Question 11

ESA
- Monitoring

Answer 11

Initiation: Monthly

Maintenance
- Dialysis: Monthly
- Non-Dialysis: Every 3 months

Iron should be monitored every 3 months (TSAT and Ferritin)

Question 12

Symptoms and Sings of CKD Anemia

Answer 12

Fatigue
Lethargy
Dyspnea

Tachycardia
Glossitis
Pallor

Question 13

When to start ESA Therapy

Answer 13

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

Question 14

Oral Iron
- Adverse Effects

Answer 14

Nausea
Vomiting
Dyspepsia
Constipation
Diarrhea
Dark Stools

Question 15

Transferrin Saturation

Answer 15

Amount of circulating iron that is available for use in the bone marrow for RBC production

Question 16

Transferrin

Answer 16

Iron transport protein (Transports iron from gut to other tissues)

Question 17

Serum Iron

Answer 17

Amount of iron in circulation that is bound to transferrin

Question 18

Ferritin

Answer 18

Main iron storage protein

Question 19

Hepcidin

Answer 19

Regulates iron by absorbing it

Increased production of Hepcidin during inflammation and infection

Question 20

Iron Deficiency
- Definition

Answer 20

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

Question 21

ESA
- Adverse Effects

Answer 21

• Hypertension
• Increased risk of vascular clotting
• Increased risk of stroke, thromboembolism, and cancer mortality
• Pure Red Cell Aplasia
• ESA Resistance

Question 22

Iron Function

Answer 22

Synthesis of hemoglobin

Synthesis of RBC

Question 23

Target Iron Levels

Answer 23

Ferritin greater than 100

TSAT 20-40%

Question 24

Relation between Anemia and CKD

Answer 24

CKD results in reduced erythropoietin synthesis
- Reduced RBC production and anemia

CKD results in iron deficiency

Anemia can result from inflammatory conditions

Question 25

Oral vs IV Iron

Answer 25

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