A Team Approach in the Effective Management of Anemia of CKD

reposted from July 2015

Anemia is considered the most prevalent hematologic complication of chronic kidney disease (CKD). It affects twice as many CKD patients as in the general population. As condition progresses through stages of CKD, anemia prevalence also increases (from 8.4% at Stage 1 to 53.4% at Stage 5.)

What is anemia?

Anemia is characterized by a decrease in hemoglobin level (<13 g/dL in men and <12 g/dL for women). Hemoglobin (Hgb) is a protein found in the red blood cells (RBC) and supplies oxygen to all the body cells. Production of red blood cells is dependent on the body’s oxygenation. What causes anemia of CKD? In healthy adults, the kidneys produce a hormone called erythropoietin (EPO), which stimulates the bone marrow to make erythropoietin or red blood cells (RBC). However, for patients with CKD, the kidneys are unable to provide sufficient amounts of EPO, resulting in anemia. With fewer Hgb, body cells and tissues are not adequately oxygenated thus resulting in anemia. Additionally, the uremic environment due to CKD significantly shortens the life span of red blood cells, from 120 to 70 days. RBCs die much faster than normal resulting in low oxygen levels in the blood. Significant blood loss from dialysis, particularly frequent blood sampling, dialyzer leaks, and incomplete blood recovery after dialysis, also contributes to the progress of anemia. Other factors associated to anemia of renal failure include impaired iron intake, bleeding problems, elevated parathyroid hormone (PTH), and poor diet and nutrition. What are the symptoms of anemia? Symptoms of anemia include pallor, fatigue, chest pain, and shortness of breath. Other symptoms attributable to anemia include weakness, poor appetite, dyspnea, poor exercise tolerance, irritability, and sexual dysfunction. With proper nutrition, sufficient iron intake, and adequate dialysis, most patients adjust well to anemia and even feel better. Despite having significantly low hemoglobin levels for weeks or even months, hematocrit level will usually stabilize by up to 30%. The difficulty of diagnosing and monitoring the progress of anemia in CKD patients makes it very important for healthcare providers to conduct thorough assessment and laboratory tests to properly manage this condition. Poorly managed anemia in CKD can lead to a host of morbidities, often serious and life-threatening. Left ventricular hypertrophy (LVH), one of the leading causes of mortality among CKD sufferers, has long been associated to anemia. How is anemia of CKD managed? Prior to erythropoiesis-stimulating agents (ESA) and intravenous iron, majority of CKD patients on dialysis suffered severe anemia. Frequent blood transfusions were the only treatment options available. Unfortunately, transfusions have a number of potential adverse effects that include increased risk of hepatitis, transfusion reactions, and iron overload. They also reduced the patient’s chances of getting a kidney transplant and were costly. Today, there are various treatment options used by healthcare practitioners in the management of CKD. Intravenous iron, ESAs (such as recombinant EPO and darbepoeitin) and other agents, and red cell transfusion are the mainstays. Following the KDIGO guidelines for the management of anemia in CKD, the physician orders the best treatment course. Majority of renal failure patients are given twice to thrice a week injections of ESAs or scheduled intravenous iron administration. Patients’ hemoglobin and hematocrit levels are continuously monitored. How important is anemia management of CKD? The importance of anemia management cannot be overstated, as it significantly affects the quality and quantity of life of our patients. To ensure effective management of anemia, most dialysis facilities follow an anemia management protocol. This protocol delegates anemia management to a non-physician staff (also called the Anemia Manager; usually a nurse or dietitian), thus allowing the healthcare team to properly monitor and manage this hematologic complication. However, this protocol should be used only as a guide and must not replace clinical judgement. The individual health concerns of the patient must be considered at all times. Why effective anemia management is a team effort? Effective management of anemia in renal failure patients requires a team approach. Every member of the healthcare team (dialysis technician, nurses, dietitian, and nephrologist) plays a crucial role in achieving and maintaining the target hemoglobin levels. • The nephrologist conducts a thorough clinical assessment and prescribes the treatment course. • The renal nurse, usually the Anemia Manager, prepares and oversees the care plan, adjusts medical management depending on patient’s response, coordinates with other team members, and conducts patient education. • The dialysis technician ensures complete blood recovery after each treatment, reports unusual bleeding and other symptoms, minimizes blood loss from frequent blood extraction, and reinforces patient education. • The renal dietitian evaluates the patient’s nutritional status, prepares and oversees the nutritional plan, and provides dietary counseling. In some dialysis facilities, a renal dietitian may also be the Anemia Manager. The patient, being the focus of care and the most important member of the healthcare team, should fully cooperate with the anemia management care plan. Full cooperation by the healthcare team helps achieve target anemia outcomes and, ultimately, quality life of patients.

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