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University Teaching Trust Treatment of renal anaemia with Erythropoeitin Stimulating Agent (ESA) Hope Building Renal Unit 0161 206 1882 © G16100301W. Design Services, Salford Royal NHS Foundation Trust, All Rights Reserved 2017. Document for issue as handout. Unique Identifier: NOE 47 (16). Review date: February 2019. Introduction What is renal anaemia? Your renal team have recommended that you have treatment for your renal anaemia. Renal anaemia is treated with a drug called Erythropoeitin Stimulating Agent (ESA). You may also hear it called EPO, Darbepoetin or Aranesp. Patients with kidney disease often develop renal anaemia. Renal anaemia is caused by a reduction in the number of red blood cells in the body. Red blood cells are important as they contain Haemoglobin (Hb) which carries oxygen around your body. Your body makes red blood cells in response to a hormone called Erythropoeitin. This hormone, Erythropoeitin, is made in the kidneys. Consequently, when you have kidney disease/ kidney impairment, you may not be producing enough Erythropoeitin. If anaemia remains untreated, symptoms can occur which can affect quality of life, these include: lTiredness / lack of energy lShortness of breath on minimal exertion lFeeling cold lLack of concentration. This booklet has been written to: lExplain to you and your family why treatment is needed lExplain the ordering and prescribing process lProvide information about the monitoring involved lRecord the details of your treatment. The chronic kidney disease (CKD) team will explain the information in this booklet before you start your treatment. 1 If anaemia is not treated, your heart may also become bigger because it has to work harder to deliver oxygen around the body. What is the treatment for renal anaemia? There are two medications you may be given to treat your renal anaemia: How will ESA be given? Unless you are on haemodialysis, ESA is given as a subcutaneous injection. This means the medication is injected into the subcutaneous layer (the fatty tissue) in your skin. The injection is usually given into the abdomen flanks, the areas either side of your belly button, as this is easy to access and provides adequate surface area to rotate sites. 1.Iron 2.ESA You may require both of these treatments. 1.Iron If your iron levels are low, you may be given iron tablets or an iron infusion. More information will be given by the medical team if you are prescribed iron. 2.ESA ESA is a medication used to replace the Erythropoeitin that your kidneys would usually make. By giving you ESA, we aim to increase the number of red cells and Haemoglobin in your blood. You can give this to your self at home or you can choose a carer, practice nurse or district nurse to give the injection for you. ESA injections are usually given once a week unless other wise directed by your renal team. You will need a sharps bin to dispose of the injections after use. © G16100301W. Design Services, Salford Royal NHS Foundation Trust, All Rights Reserved 2017. Document for issue as handout. Unique Identifier: NOE 47 (16). Review date: February 2019. 2 What are the side effects of ESA? How will I get my ESA injections? What monitoring will I need? How do I order my ESA injections? You may experience some side effects with ESA treatment. A full list of the side effects can be found on the information leaflet inside the injection box. Common side effects include: Unlike other medications, Your GP is not licensed to prescribe ESA injections. The injections are prescribed and monitored by the hospital. We will be delivered your ESA injections to you at home using a company called Fresenius. Fresenius will usually contact you to arrange a delivery time and date. One box holds 4 injections. You will need to re-order your injections, please see page 4. It will take some time for your body to make the new red blood cells that you need. ESA injections need to be ordered from the hospital by you. l Increase in blood pressure l Flu like symptoms l Skin rash l Stinging at injections site. The CKD team will be monitoring your ESA treatment closely and are happy to discuss any concerns you have about side effects. How do I store my ESA injections? ESA injections should be kept in the fridge soon as possible after being delivered. Your injection should remain in the fridge until needed. Should you find the ESA injections have not been stored correct please contact the CKD team for advice. 3 We will use a blood test called a Full Blood Count (FBC) to measure your Haemoglobin level. From this we can see how you are responding to the ESA injections and adjust the dose if needed. The blood test can be taken at your GPs and will need to be done every 2 weeks for 6 months from starting the treatment. After 6 months has passed the FBC blood test can be reduced to once a month. You will also need to take your blood pressure before you give the ESA injection. We will also check your iron levels (ferritin and iron saturations) every 3 months. It can take up to two weeks for the renal team to check your blood results and issue a new prescription. Therefore, We recommend you order your ESA injections when there are two left in the fridge. When the new prescription is issued, it is check by the hospital pharmacy before being sent to a company call Fresenius. Fresenius will deliver your new ESA injections to you at home. Please note: The renal team is unable to issue your next prescription if your have not had your blood test taken within 4 weeks of you ordering the ESA injections. We may send you a letter in the post to remind you. If your blood pressure is 180/100 or higher, do not give your injection and contact the CKD team for advice. © G16100301W. Design Services, Salford Royal NHS Foundation Trust, All Rights Reserved 2017. Document for issue as handout. Unique Identifier: NOE 47 (16). Review date: February 2019. 4 ESA dose change: The renal team may advise changing the dose or the frequency of ESA injections after reviewing your blood results. A letter would be sent in the post to confirm any changes. The letter may instruct you to use up your existing supply of injections before going onto the new dose. How do I dispose of my sharps bin? Once your sharps bin is full you can lock it by closing it fully, you will be unable to open it again after it is locked. The sharps bin can be brought back to the renal outpatients department and you can collect a new one. What happens if I miss a dose of ESA? If there is an occasion where you miss a dose of ESA , do not worry, you are not in any immediate danger. If you have missed a dose, you should take your ESA injection as soon as possible. Your next dose after this should be approximately 7 days later. Please contact the ESA order line number 0161 206 0807 when you have 2 injections at home. What do I do if I am admitted to another hospital? If you are admitted to another hospital your ESA treatment should continue. Please inform the ward staff you are being treated with ESA for renal anaemia. If the ward staff have any questions they can contact the CKD team on 0161 206 1882 We hope you will start to feel better within 6-8 weeks of starting ESA treatment. The symptoms of anaemia such as tiredness and feeling cold should improve. By treating your renal anaemia your heart will not have to work so hard to deliver oxygen around your body. This will have long term benefits to your health. Is there an alternative to ESA treatment? Where can I get more information? The only alternative to ESA treatment is regular blood transfusions. Blood transfusions carry their own risks as it is possible to have a reaction to the donated blood. If you have any questions or would like to discuss anything in this booklet, please contact the CKD team: If you receive a lot of blood transfusions this may affect your changes of receiving a kidney transplant in the future. This is because your body may develop more antibodies through the donated blood. 5 What are the benefits of ESA treatment? 0161 206 1882 0161 206 7043 © G16100301W. Design Services, Salford Royal NHS Foundation Trust, All Rights Reserved 2017. Document for issue as handout. Unique Identifier: NOE 47 (16). Review date: February 2019. 6 Initiation and Monitoring Diary In order to treat your anaemia you have been prescribed: Monitoring Diary Date Result BP ESA dose given Comments (ESA Brand) (ESA dose) (ESA frequency) Date of first injection: Date and day of next injection: Given by: Self CKD team Practice nurseOther District nurse Date of blood test (FBC/ BP): Bloods to be taken by: Practice Nurse District Nurse Renal ClinicOther Date blood test should be reduced to once a month Reminder: lYou should take your blood pressure before having your ESA injection. If your blood pressure is 180/100 or high do not give the injections and contact the CKD team lYou will need to have a blood test (FBC) every 2 weeks from the date of first injection for 6 months lAfter the 6 months is over, the blood tests can be reduced to once a month lYou will also need a blood test to check your iron levels (ferritin and iron saturations) every 3 months. 7 © G16100301W. Design Services, Salford Royal NHS Foundation Trust, All Rights Reserved 2017. Document for issue as handout. Unique Identifier: NOE 47 (16). Review date: February 2019. 8 Monitoring Diary Date Result 9 Monitoring Diary BP ESA dose given Comments Date Result BP ESA dose given Comments © G16100301W. Design Services, Salford Royal NHS Foundation Trust, All Rights Reserved 2017. Document for issue as handout. Unique Identifier: NOE 47 (16). Review date: February 2019. 10 Useful contact details Notes ESA order line number 0161 206 0807 Or email [email protected] If you have any questions or concern please do not hesitate to contact the CKD team. CKD team 0161 206 1882 or email [email protected] 11 © G16100301W. Design Services, Salford Royal NHS Foundation Trust, All Rights Reserved 2017. Document for issue as handout. Unique Identifier: NOE 47 (16). Review date: February 2019. 12 © G16100301W. Design Services Salford Royal NHS Foundation Trust All Rights Reserved 2017 This document MUST NOT be photocopied University Teaching Trust Information Leaflet Control Policy: Unique Identifier: NOE 47 (16) Review Date: February 2019 For further information on this leaflet, it’s references and sources used, please contact 0161 206 1882. If you need this interpreting please telephone Copies of this information are available in other languages and formats upon request. In accordance with the Equality Act we will make ‘reasonable adjustments’ to enable individuals with disabilities, to access this treatment / service. Email: [email protected] Under the Human Tissue Act 2004, consent will not be required from living patients from whom tissue has been taken for diagnosis or testing to use any left over tissue for the following purposes: clinical audit, education or training relating to human health, performance assessment, public health monitoring and quality assurance. If you object to your tissue being used for any of the above purposes, please inform a member of staff immediately. Salford Royal operates a smoke-free policy. For advice on stopping smoking contact the Hospital Specialist Stop Smoking Service on 0161 206 1779 Salford Royal NHS Foundation Trust Stott Lane, Salford, Manchester, M6 8HD If you would like to become a Foundation Trust Member please visit: If you have any suggestions as to how this document could be improved in the future then please visit: Telephone 0161 789 7373 www.srft.nhs.uk/ for-members http://www.srft.nhs.uk/ for-patients www.srft.nhs.uk