ANEMIAANEMIASeptember 17September 17thth, 2011, 2011

Debra Wells BSN, RN, CNNDebra Wells BSN, RN, CNN

ObjectivesObjectives Describe the symptoms of anemia, clinical Describe the symptoms of anemia, clinical

complications and how they relate to the complications and how they relate to the quality of life of dialysis patientsquality of life of dialysis patients

Describe the pathophysiology of anemia Describe the pathophysiology of anemia in dialysis patients.in dialysis patients.

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

DefinitionDefinition Anemia is a condition in which there Anemia is a condition in which there

are a decreased number of healthy are a decreased number of healthy red blood cells to carry adequate red blood cells to carry adequate oxygen to tissues and cells.oxygen to tissues and cells.

Symptoms of AnemiaSymptoms of Anemia Increased cardiac workload, LVH, tachycardia, Increased cardiac workload, LVH, tachycardia,

dyspnea, palpitations, angina, fatiguedyspnea, palpitations, angina, fatigue CNS symptoms: anorexia, insomnia, peripheral CNS symptoms: anorexia, insomnia, peripheral

numbness, decreased mental acuitynumbness, decreased mental acuity There is widespread tissue hypoxia, mucous There is widespread tissue hypoxia, mucous

membranes and skin are pale, skin loses membranes and skin are pale, skin loses elasticity, tissues atrophyelasticity, tissues atrophy

Exercise intolerance, limiting work capacity, Exercise intolerance, limiting work capacity, decreased quality of lifedecreased quality of life

Red Blood CellRed Blood Cell It’s sole purpose is to It’s sole purpose is to

transport oxygen from the transport oxygen from the lungs to the tissues.lungs to the tissues.

It cannot replicate because It cannot replicate because it does not have a nucleusit does not have a nucleus

It is formed in only one It is formed in only one place-the bone marrowplace-the bone marrow

Under normal Under normal circumstances it lives for circumstances it lives for 120 days.120 days.

The most important The most important component of the red component of the red blood cell is Hemoglobinblood cell is Hemoglobin

HemoglobinHemoglobin

Hemoglobin MoleculeHemoglobin Molecule Oxygen is not very soluble in Oxygen is not very soluble in

water (the major constituent water (the major constituent of blood), and thus an oxygen of blood), and thus an oxygen transport protein must be transport protein must be used to allow oxygen to be used to allow oxygen to be 'soluble'. Hemoglobin (Hb) is 'soluble'. Hemoglobin (Hb) is the oxygen transport protein the oxygen transport protein used in the blood.used in the blood.

Hb picks up oxygen at the Hb picks up oxygen at the lungs and delivers it to the lungs and delivers it to the tissues. Hb is able to both tissues. Hb is able to both bind and release oxygen and bind and release oxygen and is able to do these at the is able to do these at the right places! right places!

Heme GroupHeme Group

The iron is the site of The iron is the site of oxygen binding; each iron oxygen binding; each iron can bind one O2 molecule can bind one O2 molecule thus each hemoglobin thus each hemoglobin molecule is capable of molecule is capable of binding a total to four (4) binding a total to four (4) O2 molecules. O2 molecules.

Without iron in the Without iron in the heme group, there heme group, there would be no site for the would be no site for the oxygen to bind, and oxygen to bind, and thus no oxygen would thus no oxygen would be delivered to the cellsbe delivered to the cells

Normal RBC ProductionNormal RBC Production

Normal RBC ProductionNormal RBC Production

Erythropoetin Erythropoetin Erythropoetin (EPO) is a hormone Erythropoetin (EPO) is a hormone

produced and secreted from the produced and secreted from the kidney in response to hypoxia. It kidney in response to hypoxia. It travels to the bone marrow and travels to the bone marrow and stimulates the production of red stimulates the production of red blood cells.blood cells.

Minimal Serum Iron levels Minimal Serum Iron levels needed with normal kidney needed with normal kidney

functionfunction FerritinFerritin

Iron storageIron storage24ng/ml24ng/ml

Iron Saturation (TSAT)Iron Saturation (TSAT) available iron available iron

14%14% Normally enough iron is available from Normally enough iron is available from

ingested food or oral iron preparations.ingested food or oral iron preparations.

Pathogenosis of anemia of Pathogenosis of anemia of CKDCKD

• Erythropoetin deficiency Erythropoetin 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 drawingsFrequent lab drawings Higher incidence of GI bleedingHigher incidence of GI bleeding Blood loss from poor dialyzer clearanceBlood loss from poor dialyzer clearance Vitamins lost through dialysisVitamins lost through dialysis Frequent surgeryFrequent surgery InfectionInfection Retention of inhibitors, PTH, AluminumRetention of inhibitors, PTH, Aluminum

IRONIRON Causes of iron deficiency in CKDCauses of iron deficiency in CKD

Decreased iron intake due to decreased total dietary Decreased iron intake due to decreased total dietary intake of protein. intake of protein.

Absorption of iron from the intestines is diminished Absorption of iron from the intestines is diminished making oral iron supplements ineffective.making oral iron supplements ineffective.

Certain medications, such as drugs that decrease Certain medications, such as drugs that decrease gastric acidity, and certain foods can decrease iron gastric acidity, and certain foods can decrease iron absorption.absorption.

Each 1 ml loss of red blood cells results in the loss of 1 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 mg of iron. Dialysis patients may lose up to 2g of iron each year as a result of blood loss due to lab testing, each year as a result of blood loss due to lab testing, GI bleeding, retention of blood in the dialyzer and GI bleeding, retention of blood in the dialyzer and lines and bleeding of the access.lines and bleeding of the access.

Treatment with EPO will also cause iron deficiency.Treatment with EPO will also cause iron deficiency.

Impaired RBC productionImpaired RBC production

Erythropoesis Stimulating Agents Erythropoesis Stimulating Agents (ESA’s) and Intravenous iron(ESA’s) and Intravenous iron

These medications greatly improved the majority of These medications greatly improved the majority of patients lives by correcting anemia and reducing patients lives by correcting anemia and reducing need for transfusionsneed for transfusions

However, pharmacologically induced erythropoesis However, pharmacologically induced erythropoesis requires careful monitoring and adjustments.requires careful monitoring and adjustments.

And it is difficult to mimic the body’s normal And it is difficult to mimic the body’s normal mechanism of iron delivery with an iron mechanism of iron delivery with an iron administration regimen and patients responses to administration regimen and patients responses to ESA’s vary.ESA’s vary.

Most Dialysis units create nurse driven protocols with Most Dialysis units create nurse driven protocols with specific directions for multiple scenarios.specific directions for multiple scenarios.

Some units utilize an anemia manager.Some units utilize an anemia manager.

ESA Therapy ProtocolsESA Therapy Protocols Choice of ESAChoice of ESA Route and frequencyRoute and frequency Should be dosed per kg of body weightShould be dosed per kg of body weight Target Hb levels-recent CMS target goal was Target Hb levels-recent CMS target goal was

lowered to 10-11g/dLlowered to 10-11g/dL Hb monitoring schedule-at least once a monthHb monitoring schedule-at least once a month Hb variability is common in dialysis patientsHb variability is common in dialysis patients Dose adjustment criteriaDose adjustment criteria

Iron DeficiencyIron Deficiency Labs required for iron evaluationLabs 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 Absolute iron deficiency is defined as tansferrin saturation (TSAT)<20% and serum ferritin <200microg/L.(TSAT)<20% and serum ferritin <200microg/L.

Functional iron deficiency exists when iron is used up faster Functional iron deficiency exists when iron is used up faster than can be transferred from storage (ferritin). Transferrin than can be transferred from storage (ferritin). Transferrin saturation would be less than 20% and ferritin saturation would be less than 20% and ferritin approximately 300-500.approximately 300-500.

Inflammation block exists when the TSAT abruptly Inflammation block exists when the TSAT abruptly decreases along with an abrupt increase in serum ferritin. decreases along with an abrupt increase in serum ferritin. This is caused by an acute or chronic inflammation or This is caused by an acute or chronic inflammation or infection. infection.

Iron Therapy ProtocolsIron Therapy Protocols Choice of Intravenous iron productChoice of Intravenous iron product Target levelsTarget levels

TSAT goals-most protocols use 25% or even 30% as TSAT goals-most protocols use 25% or even 30% as lower limit and 50% as upper limitlower limit and 50% as upper limit

Serum ferritin-varies and is considered less important in Serum ferritin-varies and is considered less important in iron administration protocols. Lower limit is usually iron administration protocols. Lower limit is usually 500ng/ml and upper limit 1200ng/ml500ng/ml and upper limit 1200ng/ml

If levels are below lower limits, usually loading doses of If levels are below lower limits, usually loading doses of iron are recommended.iron are recommended.

If iron levels are in target, maintenance doses are If iron levels are in target, maintenance doses are needed to ensure iron repletion.needed to ensure iron repletion.

If iron levels are above limits, iron should be held If iron levels are above limits, iron should be held temporarily until next set of iron labs are drawn.temporarily until next set of iron labs are drawn.

Nursing AssessmentNursing Assessment Managing anemia requires more than just Managing anemia requires more than just

following ESA and iron protocolsfollowing ESA and iron protocols After hospitalization there is often blood After hospitalization there is often blood

loss. It is recommended to re-evaluate hb loss. It is recommended to re-evaluate hb and iron labsand iron labs

It is important to look at trending of hb and It is important to look at trending of hb and iron labsiron labs

If there are sudden decreases in hb or iron If there are sudden decreases in hb or iron labs a nursing assessment is needed and labs a nursing assessment is needed and MD should be contacted.MD should be contacted.

Not Responding to Therapy Not Responding to Therapy Protocols?Protocols?

Hyporesponsiveness to ESAHyporesponsiveness to ESA Bone marrow dysfunctionBone marrow dysfunction Inflammatory diseaseInflammatory disease InfectionInfection MD’s may order therapy outside of protocolMD’s may order therapy outside of protocol Some patients such as those receiving Some patients such as those receiving

chemotherapy for malignancy may require chemotherapy for malignancy may require transfusionstransfusions

ConclusionConclusion Anemia management is an important aspect of Anemia management is an important aspect of

care for CKD patients which has these benefits:care for CKD patients which has these benefits: Lowers mortality and hospital ratesLowers mortality and hospital rates Improves CHF and LVHImproves CHF and LVH Reduces the need for TransfusionsReduces the need for Transfusions Improves Quality of LifeImproves Quality of Life

In addition to carefully following protocols, it is In addition to carefully following protocols, it is important to evaluate the patient’s medical important to evaluate the patient’s medical status and treat the underlying etiology.status and treat the underlying etiology.