ANEMIA September 17 th, 2011 Debra Wells BSN, RN, CNN

Objectives Describe the symptoms of anemia, clinical complications and how they relate to the quality of life of dialysis patients Describe the symptoms of anemia, clinical complications and how they relate to the quality of life of dialysis patients Describe the pathophysiology of anemia in dialysis patients. Describe the pathophysiology of anemia in dialysis patients. Review the use of erythropoiesis- stimulation agents (ESAs) and iron agents and review nurse role in evaluating anemia in the dialysis patient Review the use of erythropoiesis- stimulation agents (ESAs) and iron agents and review nurse role in evaluating anemia in the dialysis patient

Definition Anemia is a condition in which there are a decreased number of healthy red blood cells to carry adequate oxygen to tissues and cells. Anemia is a condition in which there are a decreased number of healthy red blood cells to carry adequate oxygen to tissues and cells.

Symptoms of Anemia Increased cardiac workload, LVH, tachycardia, dyspnea, palpitations, angina, fatigue Increased cardiac workload, LVH, tachycardia, dyspnea, palpitations, angina, fatigue CNS symptoms: anorexia, insomnia, peripheral numbness, decreased mental acuity CNS symptoms: anorexia, insomnia, peripheral numbness, decreased mental acuity There is widespread tissue hypoxia, mucous membranes and skin are pale, skin loses elasticity, tissues atrophy There is widespread tissue hypoxia, mucous membranes and skin are pale, skin loses elasticity, tissues atrophy Exercise intolerance, limiting work capacity, decreased quality of life Exercise intolerance, limiting work capacity, decreased quality of life

Red Blood Cell It’s sole purpose is to transport oxygen from the lungs to the tissues. It’s sole purpose is to transport oxygen from the lungs to the tissues. It cannot replicate because it does not have a nucleus It cannot replicate because it does not have a nucleus It is formed in only one place- the bone marrow It is formed in only one place- the bone marrow Under normal circumstances it lives for 120 days. Under normal circumstances it lives for 120 days. The most important component of the red blood cell is Hemoglobin The most important component of the red blood cell is Hemoglobin

Hemoglobin

Hemoglobin Molecule Oxygen is not very soluble in water (the major constituent of blood), and thus an oxygen transport protein must be used to allow oxygen to be 'soluble'. Hemoglobin (Hb) is the oxygen transport protein used in the blood. Oxygen is not very soluble in water (the major constituent of blood), and thus an oxygen transport protein must be used to allow oxygen to be 'soluble'. Hemoglobin (Hb) is the oxygen transport protein used in the blood. Hb picks up oxygen at the lungs and delivers it to the tissues. Hb is able to both bind and release oxygen and is able to do these at the right places! Hb picks up oxygen at the lungs and delivers it to the tissues. Hb is able to both bind and release oxygen and is able to do these at the right places!

Heme Group The iron is the site of oxygen binding; each iron can bind one O2 molecule thus each hemoglobin molecule is capable of binding a total to four (4) O2 molecules. The iron is the site of oxygen binding; each iron can bind one O2 molecule thus each hemoglobin molecule is capable of binding a total to four (4) O2 molecules. Without iron in the heme group, there would be no site for the oxygen to bind, and thus no oxygen would be delivered to the cells Without iron in the heme group, there would be no site for the oxygen to bind, and thus no oxygen would be delivered to the cells

Normal RBC Production

Erythropoetin Erythropoetin (EPO) is a hormone produced and secreted from the kidney in response to hypoxia. It travels to the bone marrow and stimulates the production of red blood cells. Erythropoetin (EPO) is a hormone produced and secreted from the kidney in response to hypoxia. It travels to the bone marrow and stimulates the production of red blood cells.

Minimal Serum Iron levels needed with normal kidney function Ferritin Ferritin Iron storage 24ng/ml Iron Saturation (TSAT) Iron Saturation (TSAT) available iron available iron14% Normally enough iron is available from ingested food or oral iron preparations. Normally enough iron is available from ingested food or oral iron preparations.

Pathogenosis of anemia of CKD Erythropoetin deficiencyErythropoetin deficiency Decreased RBC survival timeDecreased RBC survival time Caused by uremic toxins (transfusion study)Caused by uremic toxins (transfusion study) Average lifespan 60 daysAverage lifespan 60 days Blood loss from platelet dysfunctionBlood loss from platelet dysfunction Dialysis patient has additional reasons for anemiaDialysis patient has additional reasons for anemia Frequent lab drawings Frequent lab drawings Higher incidence of GI bleeding Higher incidence of GI bleeding Blood loss from poor dialyzer clearance Blood loss from poor dialyzer clearance Vitamins lost through dialysis Vitamins lost through dialysis Frequent surgery Frequent surgery Infection Infection Retention of inhibitors, PTH, Aluminum Retention of inhibitors, PTH, Aluminum

IRON Causes of iron deficiency in CKD Causes of iron deficiency in CKD Decreased iron intake due to decreased total dietary intake of protein. Decreased iron intake due to decreased total dietary intake of protein. Absorption of iron from the intestines is diminished making oral iron supplements ineffective. Absorption of iron from the intestines is diminished making oral iron supplements ineffective. Certain medications, such as drugs that decrease gastric acidity, and certain foods can decrease iron absorption. Certain medications, such as drugs that decrease gastric acidity, and certain foods can decrease iron absorption. Each 1 ml loss of red blood cells results in the loss of 1 mg of iron. Dialysis patients may lose up to 2g of iron each year as a result of blood loss due to lab testing, GI bleeding, retention of blood in the dialyzer and lines and bleeding of the access. Each 1 ml loss of red blood cells results in the loss of 1 mg of iron. Dialysis patients may lose up to 2g of iron each year as a result of blood loss due to lab testing, GI bleeding, retention of blood in the dialyzer and lines and bleeding of the access. Treatment with EPO will also cause iron deficiency. Treatment with EPO will also cause iron deficiency.

Impaired RBC production

Erythropoesis Stimulating Agents (ESA’s) and Intravenous iron These medications greatly improved the majority of patients lives by correcting anemia and reducing need for transfusions These medications greatly improved the majority of patients lives by correcting anemia and reducing need for transfusions However, pharmacologically induced erythropoesis requires careful monitoring and adjustments. However, pharmacologically induced erythropoesis requires careful monitoring and adjustments. And it is difficult to mimic the body’s normal mechanism of iron delivery with an iron administration regimen and patients responses to ESA’s vary. And it is difficult to mimic the body’s normal mechanism of iron delivery with an iron administration regimen and patients responses to ESA’s vary. Most Dialysis units create nurse driven protocols with specific directions for multiple scenarios. Most Dialysis units create nurse driven protocols with specific directions for multiple scenarios. Some units utilize an anemia manager. Some units utilize an anemia manager.

ESA Therapy Protocols Choice of ESA Choice of ESA Route and frequency Route and frequency Should be dosed per kg of body weight Should be dosed per kg of body weight Target Hb levels-recent CMS target goal was lowered to 10-11g/dL Target Hb levels-recent CMS target goal was lowered to 10-11g/dL Hb monitoring schedule-at least once a month Hb monitoring schedule-at least once a month Hb variability is common in dialysis patients Hb variability is common in dialysis patients Dose adjustment criteria Dose adjustment criteria

Iron Deficiency Labs required for iron evaluation Labs required for iron evaluation Transferrin saturation (TSAT) refers to readily available iron. Transferrin saturation (TSAT) refers to readily available iron. Serum Ferritin refers to stored iron. Serum Ferritin refers to stored iron. Absolute iron deficiency is defined as tansferrin saturation (TSAT)<20% and serum ferritin <200microg/L. Absolute iron deficiency is defined as tansferrin saturation (TSAT)<20% and serum ferritin <200microg/L. Functional iron deficiency exists when iron is used up faster than can be transferred from storage (ferritin). Transferrin saturation would be less than 20% and ferritin approximately Functional iron deficiency exists when iron is used up faster than can be transferred from storage (ferritin). Transferrin saturation would be less than 20% and ferritin approximately Inflammation block exists when the TSAT abruptly decreases along with an abrupt increase in serum ferritin. This is caused by an acute or chronic inflammation or infection. Inflammation block exists when the TSAT abruptly decreases along with an abrupt increase in serum ferritin. This is caused by an acute or chronic inflammation or infection.

Iron Therapy Protocols Choice of Intravenous iron product Choice of Intravenous iron product Target levels Target levels TSAT goals-most protocols use 25% or even 30% as lower limit and 50% as upper limit TSAT goals-most protocols use 25% or even 30% as lower limit and 50% as upper limit Serum ferritin-varies and is considered less important in iron administration protocols. Lower limit is usually 500ng/ml and upper limit 1200ng/ml Serum ferritin-varies and is considered less important in iron administration protocols. Lower limit is usually 500ng/ml and upper limit 1200ng/ml If levels are below lower limits, usually loading doses of iron are recommended. If levels are below lower limits, usually loading doses of iron are recommended. If iron levels are in target, maintenance doses are needed to ensure iron repletion. If iron levels are in target, maintenance doses are needed to ensure iron repletion. If iron levels are above limits, iron should be held temporarily until next set of iron labs are drawn. If iron levels are above limits, iron should be held temporarily until next set of iron labs are drawn.

Nursing Assessment Managing anemia requires more than just following ESA and iron protocols Managing anemia requires more than just following ESA and iron protocols After hospitalization there is often blood loss. It is recommended to re-evaluate hb and iron labs After hospitalization there is often blood loss. It is recommended to re-evaluate hb and iron labs It is important to look at trending of hb and iron labs It is important to look at trending of hb and iron labs If there are sudden decreases in hb or iron labs a nursing assessment is needed and MD should be contacted. If there are sudden decreases in hb or iron labs a nursing assessment is needed and MD should be contacted.

Not Responding to Therapy Protocols? Hyporesponsiveness to ESA Hyporesponsiveness to ESA Bone marrow dysfunction Bone marrow dysfunction Inflammatory disease Inflammatory disease Infection Infection MD’s may order therapy outside of protocol MD’s may order therapy outside of protocol Some patients such as those receiving chemotherapy for malignancy may require transfusions Some patients such as those receiving chemotherapy for malignancy may require transfusions

Conclusion Anemia management is an important aspect of care for CKD patients which has these benefits: Anemia management is an important aspect of care for CKD patients which has these benefits: Lowers mortality and hospital rates Lowers mortality and hospital rates Improves CHF and LVH Improves CHF and LVH Reduces the need for Transfusions Reduces the need for Transfusions Improves Quality of Life Improves Quality of Life In addition to carefully following protocols, it is important to evaluate the patient’s medical status and treat the underlying etiology. In addition to carefully following protocols, it is important to evaluate the patient’s medical status and treat the underlying etiology.