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

1. ANEMIASeptember 17th, 2011Debra Wells BSN, RN, CNN

2. Objectives • 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. • Review the use of erythropoiesis-stimulation agents (ESAs) and iron agents and review nurse role in evaluating anemia in the dialysis patient

3. 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.

4. Symptoms of Anemia • Increased cardiac workload, LVH, tachycardia, dyspnea, palpitations, angina, fatigue • 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 • Exercise intolerance, limiting work capacity, decreased quality of life

5. Red Blood Cell • 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 is formed in only one place-the bone marrow • Under normal circumstances it lives for 120 days. • The most important component of the red blood cell is Hemoglobin

6. Hemoglobin

7. 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. • 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!

8. 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. • 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

9. Normal RBC Production

10. Normal RBC Production

11. 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.

12. Minimal Serum Iron levels needed with normal kidney function • Ferritin Iron storage 24ng/ml • Iron Saturation (TSAT) available iron 14% • Normally enough iron is available from ingested food or oral iron preparations.

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

14. IRON • Causes of iron deficiency in CKD • Decreased iron intake due to decreased total dietary intake of protein. • 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. • 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.

15. Impaired RBC production

16. 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 • 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. • Most Dialysis units create nurse driven protocols with specific directions for multiple scenarios. • Some units utilize an anemia manager.

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

18. Iron Deficiency • Labs required for iron evaluation • Transferrin saturation (TSAT) refers to readily available iron. • Serum Ferritin refers to stored iron. • 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 300-500. • 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.

19. Iron Therapy Protocols • Choice of Intravenous iron product • Target levels • 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 • 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 above limits, iron should be held temporarily until next set of iron labs are drawn.

20. Nursing Assessment • 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 • 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.

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

22. Conclusion • Anemia management is an important aspect of care for CKD patients which has these benefits: • Lowers mortality and hospital rates • Improves CHF and LVH • Reduces the need for Transfusions • 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.