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PHM601 AKI/CKD > Anemia in CKD > Flashcards

Anemia in CKD Flashcards

1
Q

Anemia in male Hgb value?

A

<13

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2
Q

Anemia in females Hgb value?

A

<12

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3
Q

What drives Anemia in kidney disease?

A

decrease in erythropoietin with GFR <45

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4
Q

Goals of therapy in Anemia

A
  • Increase Quality of Life
  • increase O2 carrying capacity
  • prevent/alleviate symptoms
  • decrease need for blood transfusion
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5
Q

What is the best measure of O2 carrying capacity?

A

Hgb

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6
Q

What to order for a patient on an ESA?

A

Iron panel
- serum ferritin
- transferrin saturation

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7
Q

What is serum ferritin?

A

The storage form of iron

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8
Q

What is transferrin saturation?

A

The amount of iron available for Erythropoiesis

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9
Q

Iron absorption is regulated by?

A

Hepcidin

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10
Q

What does hepcidin do?

A

inhibits ferroportin

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11
Q

How is hepcidin excreted?

A

By the kidney/renal elimination

***in CKD, hepcidin accumualtes

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12
Q

What is the most common cause of Erythropoietin resistance?

A

Iron Deficiency

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13
Q

True or False?

Correct Iron deficiency after ESA use

A

False

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14
Q

In ESRD, how often should you check iron panels?

A

Every 3 months

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15
Q

What is the response of iron deficiency treatment?

A
  • In 1-2 weeks, increase in Reticulocytes.
  • In 3-4 weeks, increase in Hgb/Hct
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16
Q

KDIGO Transferrin saturation goal?

A

> 30%

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17
Q

KDIGO serum ferritin goal?

A

> 500

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18
Q

IV Iron therapy concern/risk?

A

Iron overload
- Transferrin saturation >50%
- Serum ferritin >1200

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19
Q

Oral Iron issues

A
  • not well absorbed
  • GI side effects
  • poor adherence
  • slow iron replenish
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20
Q

IV iron issues

A
  • expensive
  • better absorbed
  • quick replenish
  • infusion/anaphylactic rxns
  • risk of iron overload
  • DO NOT USE IM***
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21
Q

Oral iron

A

Ferrous sulfate

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22
Q

IV iron

A

Ferric gluconate
Iron sucrose

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23
Q

Ferric gluconate brand name

A

Ferrlecit

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24
Q

Iron sucrose brand name

A

Venofer

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25
Q

Ferric gluconate dosing

A

125 mg TIW 8x doses

26
Q

Iron sucrose dosing

A

100 mg 1 - 3x weekly (total 1 g)

27
Q

Drugs that decrease iron absorption

A
  • Al, Mg, Ca antacids
  • Tetracyclines
  • H2 Antagonists
  • PPIs
  • Cholestyramine

***Separate by 2 hours

28
Q

Drugs affected by iron

A
  • Fluroquinolones
  • Levothyroxine
  • Tetracyclines
  • Mycophenolate
  • Methyldopa
  • Levodopa

***Separate by 2 hours

29
Q

Avoid IV iron in which patients?

A

Patients with active systemic infection

30
Q

Ferric gluconate elemental iron content

A

12.5mg/ml

31
Q

Iron sucrose elemental iron content

A

20 mg/ml

32
Q

What are ESA’s

A

Erythropoietin stimulating Agents that promote differentiation of erythroid

33
Q

Epoetin alfa vs Darbopoetin

A

Can be dosed less; longer 1/2 life
200:1 conversion

34
Q

Epoetin alfa vs Mircera

A

Mircera is very expensive and longest acting

35
Q

Epoetin alfa vs Epoetin alfa ebx

A

Biosimilar, 1:1 dose conversion
cost savings = uses less drug

36
Q

KDIGO ND-CKD ESA Initiation

A

<10

37
Q

KDIGO ESRD ESA Initiation

A

9-10

38
Q

FDA ND-CKD Initiation

A

<10

39
Q

FDA ESRD ESA Initiation

A

<10

40
Q

KDIGO ND-CKD Target

A

Do not exceed 11.5

41
Q

KDIGO ESRD ESA Target

A

Do not exceed 11.5

42
Q

FDA ND-CKD ESA Target

A

10 (avoid transfusions)

43
Q

FDA ESRD ESA Target

A

9 - 10 (avoid transfusions)

44
Q

ESA Dosing Goal change

A

1 - 2 g/dl/month

45
Q

When should you dose adjust ESA’s?

A

every 4 weeks

46
Q

How should you dose adjust ESAs

A

increase or decrease by 25%

47
Q

When should you reduce ESA dose?

A

When Hgb approaches 12g/dl
OR
If Hgb increases >1 g/dl in 2 weeks or less

48
Q

When should you increase ESA dose?

A

If Hgb is below target after 4 weeks of treatment

49
Q

ESA Hyporesponsiveness

A
  • No increase after 4 weeks of appr dosing
  • 2 ESA dose increases after stable period to maintain Hgb
50
Q

ESA Resistance

A

Target not reached after >500 unit/kg/week

51
Q

Causes of ESA Resistance

A
  • ACE inhibitor
  • Hyperparathyroidism
  • Malignancy
  • Infection
  • Iron deficiency
  • Aluminum toxicity
  • Trauma
  • Inflammation
  • B12/Folate Deficiency
52
Q

ESA Adverse Effects

A
  • Hypertension
  • Hypercoagulability (thrombosis-CVA,VTE,MI)
  • Hypersensitivity rxns
  • Pure red blood cell aplasia (No more RBC Production)
  • Malignancy Progression
  • HA/Fatigue/Edema
53
Q

ESA Black Box Warning

A

Do not exceed Hgb of 11

54
Q

ESA Monitoring Parameters

A

Iron panel monthly then quarterly
Blood pressure @each dialysis
Blood count (Hgb/Hct)

55
Q

Goals of ESA therapy

A
  1. Prevent blood transfusions
  2. Increase quality of life
56
Q

ESA Clinical Pearls

A
  • Does not improve mortality
  • IV and SQ route (SQ has longer duration of action)
  • Contraindicated in
    - Active malignancy*
    - High risk of CVA    *
    - Hgb >11***
57
Q

When to give blood transfusion?

A

In severe anemia of Hgb <7

58
Q

For every 1 unit of PRBC given…

A
  • 1 g/dl increase in Hgb
  • 200 mg of elemental iron
59
Q

Risks of blood transfusion

A
  • TRALI: Transfusion related acute lung injury
  • Hypervolemia
  • Hypocalcemia
  • Hypersensitvity rxn
  • Immune activation
60
Q

Which vitamins are depleted with dialysis?

A

Water soluble vitamins (B,C, Folic acid)

***Supplement after dialysis

PHM601 AKI/CKD (5 decks)

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