Download Mgmt of Anemia in CKD

Management of Anemia
in
Chronic Kidney Disease
Dr.
Overview
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CKD
Anemia
Anemia of CKD
Consultant pharmacist challenges with MRR for
dialysis patients
Managing and treating patients on dialysis
Cases for review
Chronic Kidney Disease (CKD)
in the U.S.

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National Kidney Foundation (NKF)
classification system 2002 for staging CKD
CKD previously called:
Chronic renal failure
 Pre-ESRD
 Renal failure
 Renal damage
 Kidney disease

KDOQI Defines CKD
Stages of Chronic Kidney
Disease
NKF Kidney Disease Outcomes Quality Initiative (K/DOQI): CKD Stages1
Stage
1
Description
GFR
(mL/min/1.73 m2)
Kidney damage with
normal or ↑ GFR
Kidney damage with
mild ↓ GFR
60-89
3
Moderate ↓ GFR
30-59
4
Severe ↓ GFR
15-29
5
Kidney failure
<15 (or dialysis)
2
Reference: 1. National Kidney Foundation. Am J Kidney Dis. 2002;39(suppl 1):S1-S266.
≥90
NKF-KDOQI Stages of CKD
CKD Continuum
ESRD
Renal Insufficiency
1
2
3
4
5
Kidney
Damage
with normal
or  GFR
Kidney
Damage
with Mild
GFR 
Moderate
GFR 
Severe
GFR 
Kidney
Failure
90
80
70
60
50
40
GFR (mL/min/1.73 m2)
NKF-K/DOQI. Am J Kidney Dis. 2002;37:S1-S266.
30
20
<15 or
Dialysis/
Transplantation (RRT)
Markers of Renal Function
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Serum creatinine
Cockcroft-Gault Equation
eCrCl
MDRD Equation
eGFR
Calculating Creatinine Clearance
Cockcroft-Gault Equation
CrCl men = (140 - Age) x LBW
Scr x 72
CrCl women = CrCl men x 0.85
Modification of Diet in Renal Disease Equation (MDRD)
CrCl men = (Scr) -1.154 x (age) -0.203
CrCl women = CrCl men x 0.742
CrCl African American = CrCl men x 1.210
http://www.mdrd.com/
USRDS: ESRD Incidence by Age
Patients Age 65 Years or Older Are More Than Twice as Likely to
Have ESRD as People Under Age 50 Years1
23%
11%
14%
1%
3%
30%
17%
Adapted from the United States Renal Data System (USRDS).1
9
Reference: 1. United States Renal Data System. 2007 annual data report reference tables: incidence.
Available at: http://www.usrds.org/2007/ref/A_incidence_07.pdf.
0-14 years
15-29 years
30-49 years
50-64 years
65-69 years
70-79 years
80+ years
In LTC Residents, the Prevalence of CKD
Increases With Age
Age-Related Prevalence
of Low GFR (%)
40% of the population had a GFR of <60 mL/min/1.73 m2 (MDRD)
n=106
6
Men
Women
5
n=671
n=3354
n=977
4
3
n=1061 n=2644
n=646
n=472
2
1
0
65-74
75-84
85-94
95+
Age in Years
n=9931
MDRD=Modification of Diet in Renal Disease.
Reference: Garg et al. Kidney Int. 2004;65:649-653.
Almost One Half of All LTC Residents Have
GFR <60 mL/min/1.73 m2
Residents with CKD
(GFR <60 mL/min/1.73 m2)
44%
44%
56%
Residents
without CKD
56%
N=4240 (residents with SCr, calculating GFR using MDRD)
SCr=serum creatinine.
Reference: Van Vleet et al. Poster presented at: American Geriatric Society Annual Meeting; May 11-15, 2005; Orlando, Fla.
CKD
Risk Factors
Contributors to Renal Function
Decline
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Decline in kidney weight, loss of nephrons
Decline in renal perfusion
Decline in GFR
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Est healthly adults lose 8-10ml/min of GFR every
decade of life beginning around age 30
Decrease in ability to concentrate urine
Decreased reabsorption of sodium
Decreased bladder capacity
Beck LH. Long-term Care Forum. 5(3) 1995.
Risk Factors for ESRD
25 Year Follow-up
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Retrospective review of 177,570 individuals
from large MCO (1964-’73)
Followed for ESRD Tx (USRDS)
842 cases ESRD observed
Goal: evaluate value of potential novel risk
factors for ESRD vs established risk factors
Chi-yuan Hsu, MD, MSc; Carlos Iribarren, MD, PhD, et al.Arch Intern Med. 2009;
169(4):342-350
Risk Factors for ESRD
25 Year Follow-up cont’d
Established Risk Factors for ESRD:
Gender (M)
Age
Proteinuria*
DM
HTN
AA race
Elevated SCr (or, decreased GFR)
Obesity*
Lower educational attainment
*most potent risk factors
Chi-yuan Hsu, MD, MSc; Carlos Iribarren, MD, PhD, et al.Arch Intern Med. 2009;
169(4):342-350
Risk Factors for ESRD
25 Year Follow-up cont’d
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Independent Risk Factors for ESRD:
 Lower Hgb
 Higher serum uric acid level (in females)
 Self-reported Hx of nocturia
 Family Hx of kidney disease
Chi-yuan Hsu, MD, MSc; Carlos Iribarren, MD, PhD, et al.Arch Intern Med. 2009;
169(4):342-350
Complications of CKD
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CVD
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“All patients with chronic kidney disease should be
considered in the ‘‘highest risk’’ group for cardiovascular
disease, irrespective of levels of traditional CVD risk factors.”
HTN (cause and complication)
Protein energy malnutrition
Central and peripheral neuropathy
 Anemia
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ESRD
Bone disease/disorders of calcium and phosphorus
National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation,
Classification and Stratification. Am J Kidney Dis 39:S1-S266, 2002 (suppl 1)
Anemia
Defining Anemia (NKF)
Group of diseases characterized by a decrease in
either Hgb, Hct or red blood cells (RBC) that
reduce the oxygen carrying capacity of the blood.
Diagnose anemia if:
- Hemoglobin < 12 g/dL (adult females)
- Hemoglobin < 13.5 g/dL (adult males)
 In patients with CKD the hemoglobin should be
11 g/dL or greater

KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in
Chronic Kidney Disease. Am J Kidney Dis 47:S1-S146, 2006 (suppl 3)
World Health Organization
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WHO definition of anemia:
Males
 Females

Hgb< 13 gm/dL
Hgb < 12 gm/dL
World Health Organization: Nutritional anemia: report of a WHO Scientific Group.
Geneva, Switzerland: World Health Organization, 1968.
Common Causes of Anemia in
Elderly Patients
Anemia of Chronic Inflammation
(inflammatory disease, infections, CKD)
Iron Deficiency Anemia
30% - 40%
Post Hemorrhagic Anemia
Vitamin B-12 and Folate Deficiency
Anemia
Chronic Leukemia or Lymphoma Anemia
5% - 10%
5% - 10%
No Identifiable Cause
15% - 25%
15% - 30%
5%
Joosten E, et al, Prevalence and causes of anemia in a geriatric hospitalized population. Gerontology 1992; 38:111-117
Cause of Anemia in Long Term Care
13.2
Chronic disease
Chronic kidney disease
15.9
Unknown
Fe, B12, folate
Other
4.0
65.6
LTC=long-term care.
Reference: Chernetsky et al. Harefuah. 2002;141:591-594.
1.3
n=481
Signs and Symptoms of Anemia Are
Nonspecific
Central nervous
system (CNS)
• Fatigue
• Headache
• Dizziness
• Syncope
• Depression
• Impaired cognition
Vascular system
• Cold intolerance
• Edema
• Pallor of skin, mucous
membranes, and
conjunctivae
Cardiorespiratory system
• Dyspnea
• Tachycardia
• Systolic ejection murmur
• Palpitations
• Cardiac enlargement
• Hypertrophy
• Wide pulse pressure
• Hypotension
• Orthostasis
Gastrointestinal system
• Anorexia
• Nausea
Genital tract
• Impotence
Reference: Morley et al. Ann Long-Term Care. 2003:S1-S21. Available at: http://www.annalsoflongtermcare.com/supplements.cfm.
Accessed February 6, 2007.
Laboratory Tests for Anemia
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Reticulocyte count (low indicates decreased RBC
production; high count may be increased RBC destruction)
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Sedimentation rate (ESR): index of
inflammation
Stool for occult blood: evaluates GI loss
Morphology by peripheral smear: size, color,
shape of RBC
Hepatic and renal function
Thyroid-stimulating hormone (TSH)
Medications That Can Cause Anemia
Red blood cell
production*
Red blood cell loss
(bleeding)
Red blood cell
survival
Alcohol
Anticoagulants
High-dose penicillin
H2 blockers
Antiplatelet agents
Sulfa agents
Metformin
Aspirin
Phenobarbital
Bisphosphonates
Phenytoin
Corticosteroids
Proton pump inhibitors Nonsteroidal
anti-inflammatory drugs
Sulfa agents
Chemotherapy agents
*Can impair vitamin B12 and folate absorption or metabolism, which impairs red blood cell
production.
Reference: American Medical Directors Association. Clinical Practice Guideline. Columbia, MD: American Medical Directors Association; 2007.
Treating Anemia
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B-12 Deficiency
 B-12 replacement
 Oral, sublingual, intranasal, IM
Folic Acid Deficiency
 Folic acid replacement
 Oral, subcutaneous, IM
Iron Deficiency
 Iron replacement (several salt forms/dose forms)
Oral, IV, IM
Anemia of Chronic Kidney Disease (CKD)
 Erythropoietic Stimulating Agents
 Epoetin Alfa (Epogen™/Procrit™), Darbepoetin Alfa
(Aranesp™)
KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in
Chronic Kidney Disease. Am J Kidney Dis 47:S1-S146, 2006 (suppl 3)
Assessing Anemia

JM 84 yo female
Dx: anemia, DM, dementia, incontinence,
osteoarthritis, osteoporosis
 Recurrent falls
 CNAs report “she won’t use the call light”
 What action, in general, should the CP take when
requested to review resident for falls for an interim
MRR?
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Iron Products and Drug Interactions
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Avoid administration with calcium, antacids,
levothyroxine, levodopa, fluoroquinolones,
PPIs, H-2 blockers
Iron and the State Operations
Manual (SOM)
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Iron does not stimulate rbc production
Iron does not correct anemia that is not caused
by iron deficiency
Document chronic use
Document doses > once daily
Documentation for “clinical rationale” may
include use of an ESA
When is “Enough” Iron “Too
Much”?
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F329 Unnecessary Drugs Table 1
“Iron therapy is not indicated in anemia of
chronic disease when iron stores and transferrin
levels are normal or elevated”
“Clinical rationale should be documented for
long-term use (> 2 months) or > 1 daily > 1
week because of side effects and risk of iron
accumulation in tissues”
Adverse Outcomes Associated With Anemia
in Older Adults
Decreased muscle
strength and
physical function1
Increased risk
of stroke10
Increased heart disease2
Anemia
Increased frequency
of hospital admission7,8
and death7-9
Increased falls3 and
fall-related injuries4
Cognitive
impairment5,6
References: 1. Penninx et al. J Am Geriatr Soc. 2004;52:719-724. 2. Zeidman et al. Isr Med Assoc J. 2004;6:16-18. 3. Guse et al. WMJ. 2003;102:37-42.
4. Herndon et al. J Am Geriatr Soc. 1997;45:739-743. 5. Zuccala et al. Am J Med. 2005;118:496-502. 6. Arygyriadou et al. BMC Fam Pract. 2001;2:5.
7. Felker et al. J Cardiol. 2003;92:625-628. 8. Li et al. Kidney Int. 2004;65:1864-1869. 9. van Dijk et al. J Am Geriatr Soc. 2005;53:660-665.
10. Abramson et al. Kidney Int. 2003;64:610-615.
Impact of Anemia on QIs
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Incidence of new fractures
Prevalence of falls
Prevalence of behavioral symptoms
Prevalence of symptoms of depression
Incidence of cognitive impairment
Prevalence of weight loss
Prevalence of dehydration
Incidence of decline in ADLs
Prevalence of little or no activity
Prevalence of psychoactive medication use
Anemia of CKD
Anemia Worsens as Kidney Function
Declines
Prevalence of Anemia (%)
100
90
80
70
60
Hb Levels
Hb=11-12 g/dL (n=181)
Hb=10-11 g/dL (n=105)
Hb=<10 g/dL (n=315)
50
10
15
15
8
40
17
62
30
20
10
9
5
14
8
43
20
0
<2
2.0-2.9
3.0-3.9
Serum Creatinine Level (mg/dL)
Reference: Adapted from Kausz et al. Dis Manage Health Outcomes. 2002;10:505-513.
>4
Etiology of CKD Anemia
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Decreased rbc production due to lack of
erythropoietin; kidneys responsible for 90% of
epo production
Increased rbc destruction due to hemolysis
Increased blood loss due to multiple
venipunctures
Decreased rbc production is present in CKD
anemia and anemia of chronic disease, and both
are normochromic, normocytic anemias
Anemia of Chronic Disease and Renal Failure. http://emedicine.medscape.com
Accessed Sept 12, 2009
Renal Anaemia
damaged
kidney
impaired production of
erythropoietin
reduced number of red blood
cells
anaemia
Erythropoietin Deficiency
Iron
Erythroid
marrow
X
Erythropoietin
RE
cells
Red blood cells
O2 delivery
RE=reticuloendothelial
Adapted from: Fauci AS, et al, eds. Harrison’s Principles of Internal Medicine. 1998; 334.
Factors That Cause or Contribute
to Anemia in CKD
•
•
•
•
•
•
•
•
α
Erythropoietin deficiency (insufficient production of
endogenous erythropoietin)
Iron deficiency
Acute/chronic inflammatory conditions
Severe hyperparathyroidism
Aluminum toxicity
Folate deficiency
Decreased RBC survival
Hemoglobinopathies (eg, alpha-thalassemia,
sickle-cell anemia)
KDOQI. Am J Kidney Dis. 2001;37(1 Suppl 1):S182-238.
Agarwal AK. J Am Med Dir Assoc. 2006;7(9 Suppl):S7-S12.
Key goals in managing anaemia of
CKD
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increase exercise capacity

improve cognitive function
regulate and/or prevent left ventricular
hypertrophy
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prevent progression of renal disease
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reduce risk of hospitalisation
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decrease mortality
What the recommendations cover
Diagnosis of anaemia of CKD
Management of anaemia of CKD
Assessment and optimisation of erythropoiesis
Maintaining stable haemoglobin
Monitoring of ACKD treatment
Assessment of Anemia in CKD

Test Hb at least annually in all patients, regardless of stage or cause of
CKD
Hct is a derived value, affected by plasma water, and, therefore, can be imprecise as a
direct assessment of erythropoiesis. In contrast to Hct, Hb values are absolute and
directly impacted by decreased erythropoietin production by the kidney1
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Assessment should include the following tests:
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A complete blood count
Absolute reticulocyte count
Serum ferritin to assess iron stores
Serum transferrin saturation (TSAT) or content of Hb in reticulocytes to assess
adequacy of iron for erythropoiesis
Stool for occult blood2
References: 1. National Kidney Foundation. Am J Kidney Dis. 2006;47(suppl 3):S1-S145.
2. National Kidney Foundation. Available at: http://www.kidney.org/professionals/kdoqi/
guidelines_updates/doqiupan_i.html.
Treatment for Anemia of CKD
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Replete iron stores to maintain:
TSAT > 20% and
 Serum ferritin >100ng/ml
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Consider erythropoiesis-stimulating agent (ESA)
Continue to evaluate responsiveness to
treatment
When treating with ESA, avoid Hgb > 12
gm/dL
Anemia of CKD Management
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Supplement iron; most patients should receive oral iron
supplement to prevent the development of iron
deficiency even if iron studies are normal at initiation of
therapy*
Select ESA therapy
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Epoetin alfa
Darbepoetin alfa
Monitor Hgb, adjust dose by 25% no more frequently
than monthly to reach and maintain target
*Wish JB, Coyne DW. May Clin Proc.2007;82:1371-80.
Hgb Target and ESAs
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Consider risk to benefit
Hgb targets
11-12 g/dL per 2007 NKF KDOQI guidelines
 10-12 g/dL per FDA package inserts
 Do not exceed Hgb >12 g/dL; adjust dose as “Hgb
approaches 12 gm/dL”
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Monitor Hgb:
Weekly: darbepoetin
 Twice weekly: epoetin
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Black Box Warning
Renal Failure: Patients experienced greater risk for
death and serious cardiovascular events when
administered ESAs to a target higher versus lower
hemoglobin level in two clinical studies.
Individualize dosing to achieve and maintain a
target hemoglobin within the range of 10 to 12
g/dL. Nov 07
Aranesp [package insert]. November 2007.
Epogen [package insert]. November 2007.
Procrit [package insert]. November 2007
Diagnosis of anaemia of CKD in adults
Treat and repeat
Hb
eGFR < 60ml/min/1.73m2
AND Hb ≤ 11 g/dl
Yes
No
Non renal and
haematinic
deficiency excluded?
No
Consider
other causes
Yes
No
See sections
1.2 & 1.3
See initial
management
algorithm
Patient on
haemodialysis?
Yes
Initial management algorithm
Yes
Ferritin < 500 µg/l?
No
Ferritin < 200 µg/l?
TSAT < 20% Or
%HRC > 6%
No
Yes
No
Yes – functional
iron deficiency
Assess Hb
Hb > 9 g/dl
Hb < 9 g/dl
ESA
(s.c.or i.v.)
and iron
Hb < 11 g/dl
i.v. iron
Assess Hb
at 6 weeks
Hb > 11 g/dl
ESA
(s.c.or i.v.)
If Hb increase < 1g/dl
after 4 weeks, increase
ESA using dose
schedule
Continue
monitoring Hb
and iron status
Assess and optimise erythropoiesis
Iron
supplements should be given to maintain
serum ferritin levels
ESA therapy is appropriate in iron-replete patients
where existing comorbidities or prognosis do not
negate its effect
Benefits of ESA therapy include improved quality
of life and physical functioning
There is no evidence to distinguish between ESAs
in terms of efficacy
Hb maintenance algorithm
(assumes ESA therapy and maintenance i.v. iron)
Measure Hb
Hb < 11 g/dl
If Hb is
persistently low
see poor
response
algorithm
↑ ESA dose/
frequency as
per schedule
unless Hb
rising by
1/g/dl/month.
Check Hb
as per
Schedule.
Hb 11–12 g/dl
No change
unless Hb
rising by
1g/dl/month
in which case
consider
ESA dose
adjustment
Hb 12–15 g/dl
Hb > 15 g/dl
Consider
stopping i.v.
iron. ↓ ESA
dose/frequency
as per schedule
unless Hb
falling by more
than 1g/dl/month.
Check Hb as
per schedule.
Stop i.v. iron.
Consider
stopping
ESA or halve
dose/frequency.
Check Hb in
2 weeks.
Ferritin < 200 µg/l?
Iron dosage schedule
Hb monitoring
Monitor treatment
Iron
status:
not earlier than
1 week after i.v. iron

routinely at
intervals of between 4
weeks and 3 months

Haemoglobin:
induction phase of
ESAs every 2–4 weeks

maintenance phase of
ESAs every 1–3 months

more actively after
ESA dose adjustment

Epoetin Alfa
Darbepoetin Alfa
Indications
• Anemia of CKD •
• Anemia of CKD
Chemotherapy induced anemia
• Chemotherapy induced
• HIV induced anemia
anemia
• elective, noncardiac,nonvascular
surgery
Dosing
Starting: 50 to 100 Units/kg
TIW
Starting: 0.45 ug/kg
Initial: 1 dose/week or
.75mcg/kg qow
Target
Hgb 10-12gm/dL
Hgb 10-12gm/dL
Dose
Response
2 to 6 weeks
2 to 6 weeks
Adapted from Package Inserts Data on File. Amgen, In; Thousand Oaks, CA
ESA Adverse Events




Hypertension, or worsening of control
Headache, arthralgias, nausea
Rarely: seizures, MI, stroke, antibody-induced
pure red cell aplasia (PRCA)
Adverse events from SQ administration
Stinging
 Necrotic tissue lesions
 Subcutaneous nodules

Hypo-responsiveness to ESAs
POTENTIAL CAUSES1-4
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Missed doses
Inadequate iron stores
 Iron deficiency is present in 25-37.5% of patients and is a common cause of
hyporesponse1
Drug/disease interactions
 Remember, iron needs an acidic environment to be maximally absorbed
B12 or folate deficiencies
Protein deficiencies
Occult blood loss
Infection/inflammation processes
Coexisting medical conditions
 Malignancies, hematological disorders
Hemolysis
1. Agarwal AK. J Am Med Dir Assoc. 2006 Nov;7(9 Suppl):S7-S12.
2. KDOQI. Am J Kidney Dis. 2001;37(1 Suppl 1):S182-238.
3. Procrit [package insert]. November 2007.
4. Aranesp [package insert]. November 2007.
ESA Monitoring
“at regular intervals” once stabilized1,2
 CBC with differential and platelet count regularly1,2
 Blood pressure should be controlled adequately before
initiation of therapy1,2
 Fe studies (TSAT, ferritin) prior to and during
therapy1,2
 Serum chemistry should be checked regularly (BUN,
creatinine, phosphorus, uric acid, K+)1
 Hgb
References: 1. Procrit [package insert]. Raritan, NJ: Ortho Biotech Products, LP; 2008. Available at: www.procrit.com/procrit/. Accessed October 23, 2008.
2. Aranesp [package insert]. Thousand Oaks, CA: Amgen Inc; 2008. Available at: www.aranesp.com/. Accessed October 23, 2008.
The Role of the Consultant Pharmacist in
the Management of the Dialysis Patient
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
CM 77yo male resident of short-stay facility
Rehab s/p laminectomy; spinal stenosis, gout, DM,
HTN, CAD, COPD, RA, renal failure
Dialysis TIW
Weight



Pre-dialysis
Post-dialysis
79.6 kg
77.5 kg
Blood pressure


Pre-dialysis
Post-dialysis
192/76
163/74
Additional Information
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Continuous oxygen at 2L/min
Renal diet
Fluid restriction 1000cc qd
Labs:
Hgb 9.9 gm/dL
 Glucose 86 mg/dL
 SCr 6.1; eGFR 10ml/min
 K+ 4.7 mEq/L
 Calcium 9.1 mg/dL

Current Medications
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Zyloprim 300mg qd
Colchicine .6mg qd
Glipizide 10mg qd
Simvastatin 80mg qhs
Diovan 320mg bid
Clonidine .1mg q12h
Hydralazine 50mg bid
Metoprolol 25mg bid

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Furosemide 40mg qd
Phos-Lo 667mg qd
w/meal
Nephrocaps qd
Docusate 100mg bid
Chemsticks ac & hs
Fosrenal 2000mg w/
each meal
What’s a
Consultant to do???
The Role of the Consultant Pharmacist in
the Management of the Dialysis Patient




CM 77yo male resident of short-stay facility
Rehab s/p laminectomy; spinal stenosis, gout, DM,
HTN, CAD, COPD, RA, renal failure
Dialysis TIW
Weight



Pre-dialysis
Post-dialysis
79.6 kg
77.5 kg
Blood pressure


Pre-dialysis
Post-dialysis
192/76
163/74
Additional Information




Continuous oxygen at 2L/min
Renal diet
Fluid restriction 1000cc qd
Labs:
Hgb 9.9 gm/dL
 Glucose 86 mg/dL
 SCr 6.1; eGFR 10ml/min
 K+ 4.7 mEq/L
 Calcium 9.1 mg/dL

Current Medications

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Zyloprim 300mg qd
Colchicine .6mg qd
Glipizide 10mg qd
Simvastatin 80mg qhs
Diovan 320mg bid
Clonidine .1mg q12h
Hydralazine 50mg bid
Metoprolol 25mg bid
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Furosemide 40mg qd
Phos-Lo 667mg qd
w/meal
Nephrocaps qd
Docusate 100mg bid
Chemsticks ac & hs
Fosrenal 2000mg w/
each meal
Case Studies
The Role of the Consultant Pharmacist
in the Management of
Anemia of CKD
Case 1
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RB is an 85yo male resident of a LTCF
Two months ago he was started on ferrous
sulfate 325mg bid for “anemia”
Follow-up labs
Hgb 8.1 g/dl
 Hct 32%
 Iron 45 mcg/dl
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Recent hospital return on epoetin alfa 30,000
units TIW (wt 75kg)
Case 1 cont’d
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CP recommends lab
Hgb 8.9 g/dl
 Hct 35%
 TSAT 18%
 Ferritin 92 ng/ml
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Hgb has not increased significantly over 4 weeks
TSAT should be >= 20%
 Ferritin >= 100ng/ml
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Case 1 cont’d
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Consider possible causes for lack of rise in Hgb
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Appropriate dosing?
30,000 units TIW for 75 kg patient; the recommended
starting dose for epo is 50-100 units/kg TIW, IV or SC
 The starting dose range based on weight would be 37,500
– 75,000 units TIW
 If Hgb does not increase by 1g/dl after 4 weeks and iron
stores are adequate, increase dose by 25%
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Case 1 cont’d
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Are iron stores adequate in this resident?
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No, based on reported labs
CP discusses administration of iron with nurses
PRN antacid is frequently given with the iron to reduce
c/o of GI upset; or, doses are held
For optimal absorption, iron should be given 1 hr
before or 2 hrs after meals, but may be given with food
to reduce GI irritation
Case 1 cont’d
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What action should be taken by the CP?
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Educate staff on proper administration of iron
Recommend to prescriber to increase epo dose to 40,000
units TIW
Check iron, ferritin, TSAT in about a month
Hgb should be checked at least weekly x 4 after a dosage
change (then monthly, when stabilized)
Clinically significant improvements may not be seen for
2-6 weeks, but do not adjust dose any more frequently
than once per month
Case 2
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JC is an 80yo female resident of a LTCF
Primary Dx: HTN, anemia of CKD
Hgb 8.7 g/dl
Taking 45,000 units erythropoietin TIW x 4
weeks, Hgb results:
Week 1
 Week 2
 Week 3
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9.1 g/dl
10.1 g/dl
11.9 g/dl
Case 2
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If there is a rapid increase in Hgb (>1g/dl in any
2 week period) OR
The Hgb is increasing and approaching 12
Reduce weekly dose by approximately 25%
Rapid rise increases risk of exacerbation of HTN
ESAs should not be used in patients with
uncontrolled HTN