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Iron metabolism And Anemia in chronic kidney disease Chittima Sirijerachai.

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Presentation on theme: "Iron metabolism And Anemia in chronic kidney disease Chittima Sirijerachai."— Presentation transcript:

1 Iron metabolism And Anemia in chronic kidney disease Chittima Sirijerachai

2 Iron distribution –Intracellular ferrous iron Heme iron compound : Hb, myoglobin Iron containing enzyme –Intracellular ferric iron RE cell, heart, epithelial cell of small intestine - Ferric-transferrin Intracellular iron Extracellular iron

3 Dietary iron 1-2 mg/day Liver 1000 mg Spleen 600 mg Plasma transferrin 3 mg Slough mucosal cell 1-2 mg/day Myoglobin 300 mg utilization Bone marrow 300 mg Erythrocyte 1800 mg utilization

4 Iron absorption Fe +++ Fe ++ ferritin Fe transferrin Promote absorption -Fructose -Vitamin C -Heme iron -Amino acid Inhibit absorption -Phosphate -Phytate -Tannin -Soil clay HCl

5 Iron absorption

6 Regulation of iron absorption Dietary iron – mucosal block Iron stores – store regulator Erythropoitic regulator

7 Heme Iron utilization

8 Dietary iron 1-2 mg/day Liver 1000 mg Spleen 600 mg Plasma transferrin 3 mg Slough mucosal cell 1-2 mg/day Myoglobin 300 mg utilization Bone marrow 300 mg Erythrocyte 1800 mg utilization Iron deficiency anemia

9 Plasma Fe-Tf Liver spleen Bone marrow rbc inflammation hepcidin Anemia of chronic disease

10 Iron study Serum iron Total iron binding capacity (TIBC) Transferrin saturation (Tf sat) Ferritin

11 Iron depletion erythrocyte Iron stores normalfunctional absolute Serum ferritin (ng/ml) > 100 < 100 Tf sat % > 20< 20

12 - iron - protein - etc erythropoietin Decreased production Blood loss Increased destruction

13 Causes of anemia in ESRD Decrease erythropoietin Iron deficiency Nutritional deficiency Decrease red cell survival Bone marrow suppression by uremia Osteitis fibrosa cystica Inflammation Aluminum toxicity

14 Work-up for a diagnosis of anemia in CKD Work-up for a diagnosis of anemia in CKD Adult male< 13.5 g/dl Adult female<12.5 g/dl Hb

15 Diagnosis of renal anemia Significant impairment of renal function No other causes of anemia Iron deficiency anemia Nutritional deficiency anemia GFR 2 mg/dl

16 Diagnosis of renal anemia History taking Physical examination - Dietary intake - Chronic blood loss

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18 Investigation CBC Iron study, ferritin Red cell indices

19 CBC and RBC indices fl pg g/dl %

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21 Iron study, ferritin TSAT < 20 % Ferritin < 100 ng/ml Iron deficiency anemia

22 Treatment of renal anemia

23 Benefit of anemia control in ESRD Increased survival Decreased cardiac complication Improved quality of life Increased exercise capacity Decreased hospitalization

24 Target for anemia treatment Hb > 11 g/dlHct > 33 % Within 4 months Ferritin ng/ml TSAT %

25 Treatment of renal anemia Eryhtropoietin Adequate dialysis Nutritional support Iron therapy

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27 Improved response to EPO Reduced dose of EPO

28 Iron therapy VS Oral iron IV iron Iron sucrose (venofer)

29 Iron therapy - Ferrous sulfate1 x 3 - Iron sucrose mg/wk Monitor:-serum ferritin, TSAT q 1-3 months

30 Iron therapy in CKD Serum ferritin Transferrin saturation < 100 ng/ml- iron deficiency > 800 ng/ml- stop iron Rx < 20 %- iron deficiency > 50 %- stop iron Rx

31 Side effects of iron therapy Oral iron - GI irritation - Diarrhea - Constipation IV iron - anaphylactoid - hypotension - muscle cramp

32 Erythropoietin Erythropoietin  Erythropoietin  Recormon Eprex Eporon Epokrine

33 Erythropoietin U/kg/wkSC U/kg/wkIV Hb 1-2 g/dl/month

34 Erythropoietin Side effects - hypertension - PRCA - headache - Thrombosis

35 Inadequate erythropoietin response Patient fail to attain the target Hb while receiving:- EPO 300 U/kg/wk SC EPO 450 U/kg/wk IV 4-6 months

36 Inadequate erythropoietin response Iron deficiency anemia Chronic blood loss Chronic inflammation Inadequate dialysis hyperparathyroidism

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