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830 > CKD Anemia > Flashcards

CKD Anemia Flashcards

1
Q

Patho of CKD Anemia

A
  • PRIMARY CAUSE: decreased production of EPO by kidney (normally supplies 90% of body’s EPO)
  • Uremia: shortens RBC lifespan
  • Changes in Fe regulation: hepcidin
  • Hyperparathyroidism
  • Infection or inflammatory conditions
  • Blood loss form hemodialysis or blood draws
  • Platelet dysfunction: GI bleed
  • RBCs destroyed during hemodialysis
  • Water soluble vitamins removed by dialysis
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2
Q

Presentation of Anemia

A
  • Pallor
  • Fatigue
  • Tachycardia
  • Dyspnea
  • Poor exercise tolerance
  • Angina
  • Anorexia
  • Cold extremeties
  • Weakness
  • Depression
  • Insomnia/excessive sleepiness
  • LVH (left ventricular hypertrophy)
  • Decreased cognitive function, mental alterness, energy level, and sexual function
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3
Q

Why treat Anemia?

A

-Hbg < 10 g/dL has been shown to have clear evidence towards LVH, deterioration in cerebral function, and decreased quality of life

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4
Q

CV Consequences of Anemia

A

Reduced Hgb ==> Tissue Hypoxia ==> Increased cardiac workload and neurohormonal activation ==> LVH/IHD (also encourage the development of one another) ==> CHF, MI, arrhythmias

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5
Q

Hemoglobin Reference Ranges

A
  • Men: 14.5 - 18 g/dL

- Women: 12 - 16 g/dL

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6
Q

What to always assess/fix first

A

IRON

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7
Q

Iron to Treat Anemia

A
  • Anemic + Not on iron/ESA, recommend trial IV iron if: increase in ESA without starting ESA desired and TSAT =< 30% and ferritin is =< 500 ng/mL
  • Goal: keep Hgb > 10 g/dL to avoid ESA therapy

-ESA patients not on iron, recommend iron trial if: increase in Hgb or decrease in ESA dose desired and TSAT =< 30% and ferritin is =< 500 ng/mL

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8
Q

Iron to Treat Anemia

A

Minimum TSAT/[Ferritin]:
CKD-ND, CKD-PD
-TSAT > 20%
-Serum ferritin > 100 ng/mL

CKD-HD

  • TSAT > 30%
  • Serum ferritin > 200 ng/mL
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9
Q

Oral Iron Preps

A

-Recommended dose: 200 mg elemental iron/day

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10
Q

Iron Formulation + Amount of Elemental Iron

A
  • Ferrous gluconate 315 mg = 36 mg elemental iron
  • Ferrous sulfate 325 mg = 65 mg elemenntal iron
  • Ferrous fumarate 300 mg = 99 mg elemental iron
  • All other formulations are 100% elemental iron
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11
Q

Oral Iron AE

A
  • GI symptoms: dyspepsia, N/V, abdominal cramping
  • Constipation/diarrhea
  • Dark Stools
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12
Q

Oral Iron Drug Interactions

A
  • Food can decrease absorption
  • Antacids can decrease absorption
  • Drugs that increase pH (PPIs and H2RAs) can decrease Fe absorption
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13
Q

Oral Iron + Food

A
  • Recommended to take on an empty stomach

- If not tolerated, can take with food

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14
Q

Oral Iron decreases absorption of….

A
  • Levothyroxine
  • Antibiotics: quinolones, tetracyclines
  • Some HIV medications
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15
Q

IV Iron Preps

A
  • Iron dextran (INFeD)
  • Iron sucrose (Venofer)
  • Ferric carboxymaltose (Injectafer)
  • Ferric pyrophosphate citrate (Triferic)
  • Ferumoxytol (Feraheme)
  • Sodium ferric gluconate (Ferrlecit)

Better for dialysis patients

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16
Q

IV Iron + Anaphylatic Reactions

A
  • Reported with ALL formulations of IV Fe
  • Highest rates seen with iron dextran (test dose of 25 mg first)
  • Sodium ferric gluconate, iron sucrose, ferumoxytol have better safety records
  • Observe during and immediately following administration for at least 30 minutes and until stable (60 minutes for dextran)
  • Crash cart and personnel available to provide treatment)
17
Q

Iron Overload

A
  • Excess iron can deposit in the tissues
  • Can cause dysfunction of key organs like heart, pancreas, and liver
  • Evaluate holding iron when ferritin > 500 ng/mL
18
Q

Is it okay to give IV iron when they patient has an active systemic infection?

A

No

19
Q

Monitoring for Iron Therapy

A
  • Assess iron before starting ESA
  • Test more frequently with ESA introduction/dose changes, with blood loss, and when monitoring response to course of IV Fe
  • Test every 3 months for patients on stable ESA dose
  • Monitor CBC for Hgb levels
20
Q

Targets of Iron Treatment

A
  • Ferritin

- TSAT

21
Q

Erythropoietic Stimulating Agents

A
  • ESA
  • Same biological effects as endogenous EPO
  • Stimulates erythroid progenitor cell proliferation and differentiation
  • Increases Hgb synthesis
  • Induce release of reticulocytes from bone marrow into blood stream
22
Q

ESA Products

A
  • Epoetin Alfa
  • Darbepoetin Alfa
  • Methoxy Polyethylene Glycol-Epoetin Beta
23
Q

Epoetin Alfa

A
24
Q

Epoetin Alfa

A
  • Epogen (Amgen), Procrit (Janssen), Retacrit (Pfizer, biosimilar)
  • 30 kDA - amino acid sequence similar to natural EPO
  • 1/2 Lives: IV = 4-13 hours, SC = 19-25.3 hours
25
Q

Darbpoetin Alfa

A
  • Aranesp (Amgen)
  • 2 additional carbohydrate chains - larger molecular weight (37 kDa)
  • 1/2 Lives (longer than Epoetin): IV = 25.3 hours, SC = 28.8 hours
26
Q

Methoxy Polyethylene Glycol-Epoetin Beta

A
  • Mircera (Roche)
  • 60 kDa
  • Longest half lives: IV = 134 hours, SC = 139 hours
27
Q

When to Start ESA?

A
  • Use with great caution, if at all, in CKD patients with: active malignancy, history of malignancy, history of stroke
  • If on dialysis, start ESA when Hgb is 9-10 g/dL
  • If not on dialysis and Hgb < 10 g/dL, individualized based on many factors
28
Q

Individualized Factors + ESA Initiation

A
  • Rate of Hgb fall
  • Prior response to Fe therapy
  • Risk of needing blood transfusion
  • Risk related to ESA therapy
  • Presence of anemia-related symptoms
29
Q

ESA Starting Doses

A

Epoetin Alfa
-Dialysis/Non-dialysis: 50-100 U/kg IV/SC 3x/week

Darbepoietin Alfa

  • Dialysis: 0.45 ug/kg IV/SC every week or 0.75 ug/kg q2w
  • Non-Dialysis: 0.45 ug/kg SC q4w

Epoetin Beta
-Dialysis and Non-dialysis: 0.6 ug/kg IV/SC q2w

30
Q

Hgb Levels + ESA

A
  • Should not be used to maintain [Hgb] > 11.5 g/dL

- Should not be used intentionally to increase [Hgb] > 13 g/dL

31
Q

Epoetin Alfa Dose Adjustments

A
  • Monitor Hgb at least every week while adjusting/starting therapy until stable, then at least once a month
  • Do not increase dose more than once a month
  • If Hgb increases >1 g/dL in 2 weeks, decrease dose by >=25%
  • If Hgb dose not increase >1 g/dL after 4 weeks, then increase dose by 25%
  • For patients who don’t respond adequately over 12 week period, increases in ESA is unlikely to improve response and may increase their AE risks
32
Q

Causes for ESA Resistance

A
  • Iron deficiency
  • Vitamin deficiencies: folic acid, B12
  • Drug-induced anemia
  • Patient compliance with ESA, iron, dialysis
  • PRCA
  • Also infection, malnutrition, malignancy, blood disease, intoxications, blood loss, inadequate dialysis
33
Q

Pure Red Cell Aplasia

A
  • PRCA
  • Develop neutralizing antibodies to EPO
  • Presentation: sudden loss of response to ESA therapy (Rapid drop in Hgb), low reticulocyte count
  • Management: D/C ESA agent and do NOT switch to a different agent
  • Can also use corticosteroids + cyclosporine/cyclophosphamide, blood transfusions for anemia
34
Q

ESA AE

A
  • Common: HTN
  • Serious: increased mortality, MI, stroke, and thromboembolism
  • Seizures
  • PRCA

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