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Anemia in CKD (Signs/sx (fatigue, dec. energy, pallor, BUT is this anemia…
Anemia in CKD
Signs/sx
fatigue
dec. energy
pallor
BUT is this anemia or just d/t CKD, hemodialysis, or HPTH?
Pathophys
CKD leads to less EPO
Absorb less iron from gut d/t less
hepcidin
Dialysis causes blood loss
RBC life is ~1/2 that of normal in CKD
Diet - CKD pts often on diet restrictions
Labs
Hgb low (8.6)
Consider transfusion if Hgb < ___
TSAT goal >20%
Ferritin
Vit B12 and folate
Treatment
IV iron
Iron dextran
Ferric sucrose
Ferric gluconate
MUCH cheaper than ferric sucrose (although ESRD = Medicare coverage)
Dose: 1,000 mg loading
ADRs
Infusion reactions
Monitor
Tsat (don't want >50%)
Oral iron potencies:
fumarate > sulfate > gluconate
Maintenance doses: NEJM study compared giving 400 qMonth or giving 400 PRN low iron. Routine doses ARE better for control.
Goals
Replete iron
Inc. hgb to >9
Prevent getting Hgb too high (13-14)
Improve energy/sx -> QoL
Prevent need for blood transfusion
These inc risk of rejecting future kidney transplant
Titrating EPO dose
Get iron under control first
Then increase EPO by up to 25% each time
biosimilar -> Retacrit is go-to
EPO in high BP:
Do not exceed 500 u/kg/wk
ADRs
ischemic stroke
Med-related
causes?
Dialysis pts don't absorb PO iron well
EPO will
not
work if iron deficient