Presentation is loading. Please wait.

Presentation is loading. Please wait.

Renal Anaemia Dr Anne Kleinitz KRSS GP. Why is this important? Anaemia is common in the Kimberley Anaemia is common in the Kimberley Multiple causes,

Similar presentations


Presentation on theme: "Renal Anaemia Dr Anne Kleinitz KRSS GP. Why is this important? Anaemia is common in the Kimberley Anaemia is common in the Kimberley Multiple causes,"— Presentation transcript:

1 Renal Anaemia Dr Anne Kleinitz KRSS GP

2 Why is this important? Anaemia is common in the Kimberley Anaemia is common in the Kimberley Multiple causes, but common in CKD and ESKD. Multiple causes, but common in CKD and ESKD. Anaemia is linked to left ventricular dysfunction, heart failure, reduced exercise tolerance and reduced quality of life. Anaemia is linked to left ventricular dysfunction, heart failure, reduced exercise tolerance and reduced quality of life. Pts who are on erythropoietin eg. Aranesp, have increased iron requirements and usually require IV iron. Pts who are on erythropoietin eg. Aranesp, have increased iron requirements and usually require IV iron.

3 Objectives Definition of Anaemia Definition of Anaemia Causes Causes Symptoms and Signs Symptoms and Signs Investigations Investigations Management of renal anaemia Management of renal anaemia Case studies Case studies

4 Definition of Anaemia Greek term for “no blood” Greek term for “no blood” Term used to refer to a shortage of red blood cells (RBC) or a reduciton in their haemaglobin (Hb) content. Term used to refer to a shortage of red blood cells (RBC) or a reduciton in their haemaglobin (Hb) content. Hb is a molecule in RBCs that carries oxygen. Hb is a molecule in RBCs that carries oxygen. May be due to low red cell mass, or increased plasma volume (eg. pregnancy) May be due to low red cell mass, or increased plasma volume (eg. pregnancy)

5 Hb level in anaemia Male <13.5 g/dL Male <13.5 g/dL Female <11.5g/dL Female <11.5g/dL In CKD aim for Hb between 11 – 12 g/dL (see CKD protocol) In CKD aim for Hb between 11 – 12 g/dL (see CKD protocol) Level at which we consider EPO in CKD < 10.0 g/dL Level at which we consider EPO in CKD < 10.0 g/dL

6 Erythropoeisis RBCs develop in the bone marrow as stem cells, then evolve into erythroblasts. RBCs develop in the bone marrow as stem cells, then evolve into erythroblasts. Erythropoeitin (EPO) is a hormone secreted (90%) from proximal renal tubules. Erythropoeitin (EPO) is a hormone secreted (90%) from proximal renal tubules. EPO stimulates stem cells in the bone marrow to  RBC production. EPO stimulates stem cells in the bone marrow to  RBC production. Iron essential in latter phase as Hb incorporated into reticulocytes and released into circulation as RBCs Iron essential in latter phase as Hb incorporated into reticulocytes and released into circulation as RBCs 2/3 rds of iron in the body is in Hb 2/3 rds of iron in the body is in Hb

7 Renal Anaemia Anaemia of renal failure is normocytic and normochromic Anaemia of renal failure is normocytic and normochromic ie. Normal size and normal Hb concentration ie. Normal size and normal Hb concentration Unless they also have iron deficiency Unless they also have iron deficiency

8 Classification of Anaemia Mean cell volume (MCV) Mean cell volume (MCV) average size of one RBC average size of one RBC Microcytic MCV < 80 Microcytic MCV < 80 Normocytic Normocytic Macrocytic > 100 Macrocytic > 100

9 Microcytic MCV < Iron deficiency anaemia – most common Iron deficiency anaemia – most common Thalassemia Thalassemia

10 Microcytic hypochromic RBCs

11 Normocytic Acute blood loss Acute blood loss Anaemia of chronic disease Anaemia of chronic disease Bone marrow failure Bone marrow failure Renal failure Renal failure Hyopthyroidism (or  MCV) Hyopthyroidism (or  MCV) Haemolysis (or  MCV) Haemolysis (or  MCV) Pregnancy Pregnancy

12 Normocytic RBCs

13 Macrocytic B12 or folate deficiency B12 or folate deficiency Alcohol excess or liver disease Alcohol excess or liver disease Reticulocytosis (eg. With haemolysis) Reticulocytosis (eg. With haemolysis) Cytotoxics Cytotoxics Myelodysplastic syndromes Myelodysplastic syndromes Marrow infiltration Marrow infiltration Anti-folate drugs (eg. Phenytoin) Anti-folate drugs (eg. Phenytoin) Hypothyroid Hypothyroid

14 Macrocytic/megaloblastic RBCs

15 Objectives Definition of Anaemia Definition of Anaemia Causes Causes Symptoms and Signs Symptoms and Signs Investigations Investigations Management of renal anaemia Management of renal anaemia Case studies Case studies

16 Causes of Anaemia Reduced production of RBC Reduced production of RBC Accelerated breakdown of RBC Accelerated breakdown of RBC Increased loss of RBC Increased loss of RBC

17 Causes of Anaemia in renal failure Reduced Production of RBC Reduced Production of RBC May be secondary to shortage of RBC precursors such as Iron, B12 and folate. May be secondary to shortage of RBC precursors such as Iron, B12 and folate. Reduced oral intake Reduced oral intake on a low phosphate or protein diet this may effect dietry iron on a low phosphate or protein diet this may effect dietry iron Uraemic patients may have reduced appetites Uraemic patients may have reduced appetites Reduced absorption Reduced absorption Phosphate binders may reduce absorption Phosphate binders may reduce absorption Proton pump inhibitors Proton pump inhibitors Inadequate erythropoietin, 90% produced in kidneys, the hormone that stimulates erythropoiesis (manufacture of erythrocytes) Inadequate erythropoietin, 90% produced in kidneys, the hormone that stimulates erythropoiesis (manufacture of erythrocytes)

18 Accelerated Breakdown Accelerated Breakdown Impaired cell survival (90 days Vs 120 days) Impaired cell survival (90 days Vs 120 days) Patients of haemodialysis have RBC destruction. Patients of haemodialysis have RBC destruction. Increased loss Increased loss Stress ulceration from chronic disease may result in GIT loss Stress ulceration from chronic disease may result in GIT loss Dialysis Dialysis HD pts lose ~ 2.5 L/yr HD pts lose ~ 2.5 L/yr

19 Anaemia in CRF

20 Anaemia in CKD Significant anaemia noted once eGFR < 40 Significant anaemia noted once eGFR < 40 Even with eGFR 30 – 40, consider other causes of anaemia Even with eGFR 30 – 40, consider other causes of anaemia Beware of anaemia that is out of proportion to level or renal impairment. Beware of anaemia that is out of proportion to level or renal impairment.

21 Objectives Definition of Anaemia Definition of Anaemia Causes Causes Symptoms and Signs Symptoms and Signs Investigations Investigations Management Management Case studies Case studies

22 Symptoms Fatigue, reduced exercise tolerance Fatigue, reduced exercise tolerance Dyspnoea/Shortness of breath Dyspnoea/Shortness of breath Syncope/faintness Syncope/faintness Palpitations. Angina if pre-existing CAD Palpitations. Angina if pre-existing CAD Cognitive impairment; memory concentration Cognitive impairment; memory concentration Loss of libido Loss of libido Altered menstrual cycles Altered menstrual cycles Erectile dysfunction Erectile dysfunction

23 Signs May be absent May be absent Pallor – eg. Conjunctivae Pallor – eg. Conjunctivae Hyperdynamic circulation Hyperdynamic circulation Tachcardia Tachcardia flow murmur (ESM, loudest over apex) flow murmur (ESM, loudest over apex) cardiomegaly cardiomegaly Later, heart failure may occur. Later, heart failure may occur.

24 Objectives Definition of Anaemia Definition of Anaemia Causes Causes Symptoms and Signs Symptoms and Signs Investigations Investigations Management Management Case studies Case studies

25 Investigations FBC FBC Hb Hb WCC WCC Platelets Platelets MCV MCV RCC RCC Htc Htc B12 B12 necessary for rapid synthesis of DNA during cell division necessary for rapid synthesis of DNA during cell division Folate Folate Required for cell division in bone marrow to produce RBC’s Required for cell division in bone marrow to produce RBC’s Iron studies Iron studies Iron Iron Ferritin Ferritin Transferrin Transferrin Transferritin saturation (TSAT) Transferritin saturation (TSAT) CRP CRP Inflammatory marker Inflammatory marker

26 Reticulocyte count Erythrocyte precursors that are released from the bone marrow and circulate in the blood as they mature into RBC’s Erythrocyte precursors that are released from the bone marrow and circulate in the blood as they mature into RBC’s Indicates the level of erythropoietic activity in the bone marrow Indicates the level of erythropoietic activity in the bone marrow Normal 0.2% – 2% Normal 0.2% – 2% Most helpful if very low (<0.1%) or greater than 3% Most helpful if very low (<0.1%) or greater than 3% Decreased reticulocytes seen in EPO deficiency, Iron, vitamin B12 and folate deficiency. Decreased reticulocytes seen in EPO deficiency, Iron, vitamin B12 and folate deficiency.

27 Target Hb CARI Guidelines Minimum Hb concentration in dialysis pts is 110 – 120 g/L Minimum Hb concentration in dialysis pts is 110 – 120 g/L In CKD In CKD Males < 13.5 g/dL Males < 13.5 g/dL ( 70 years) ( 70 years) Female < 11.5 g/dL Female < 11.5 g/dL

28 Objectives Definition of Anaemia Definition of Anaemia Causes Causes Symptoms and Signs Symptoms and Signs Investigations Investigations Management Management Case studies Case studies

29 Management of renal anaemia Look for other causes of anaemia Look for other causes of anaemia ? malignancy ? malignancy Correct other RBC precursors Correct other RBC precursors B12, folate B12, folate Intravenous Iron supplementation Intravenous Iron supplementation Correct EPO deficiency with erythropoietin replacement therapy (ERT) Correct EPO deficiency with erythropoietin replacement therapy (ERT) Blood transfusions - very cautiously Blood transfusions - very cautiously Monthly monitoring of Hb and ferritin. Monthly monitoring of Hb and ferritin.

30 ERT available in WA Eprex (Epoeitin alpha) Eprex (Epoeitin alpha) IV only IV only 3 x wk 3 x wk Most HD pts on this Most HD pts on this Neorecormon (Epoeitin beta) Neorecormon (Epoeitin beta) Aranesp (Darbepoeitin) Aranesp (Darbepoeitin) IV or SC IV or SC extra carbohydrate chain, 3 x longer half life, hence can be given weekly or fortnightly (non-dialysing pts). extra carbohydrate chain, 3 x longer half life, hence can be given weekly or fortnightly (non-dialysing pts). ** Cold chain required for ERT. ** ** Cold chain required for ERT. **

31 Initiating ERT Started by nephrologist Started by nephrologist For funding pts need to meet S100 criteria For funding pts need to meet S100 criteria GFR less then 60mls/min GFR less then 60mls/min Hb less than 100 g/L Hb less than 100 g/L Before commencing therapy Before commencing therapy Iron stores *** likely an ongoing requirement Iron stores *** likely an ongoing requirement red cell folate red cell folate Vitamin B12 Vitamin B12

32 EPO administration Avoid increases greater than 10g/L month Avoid increases greater than 10g/L month Generally adjustments 25% of dose Generally adjustments 25% of dose Aim for Hb110 – 120 g/L Aim for Hb110 – 120 g/L TSAT > 20% TSAT > 20% Ferritin around 600 Ferritin around 600

33 Logistics of Aranesp Robyn’s demonstration of use…

34 Concerns with ERT therapy Hypertension, especially if Hb  quickly Hypertension, especially if Hb  quickly Ideally < 180 systolic. Ideally < 180 systolic. Discuss with renal GP if unsure Discuss with renal GP if unsure HPT may be indicative of fluid overload, so may need 2/24 bags prior to EPO HPT may be indicative of fluid overload, so may need 2/24 bags prior to EPO Seziures Seziures Up to 3% in first 3/12 of Rx Up to 3% in first 3/12 of Rx Pure red cell aplasia (PRCA) Pure red cell aplasia (PRCA)

35 Causes of EPO not working Iron deficiency ** most common ** Iron deficiency ** most common ** B12 & Folate deficiency B12 & Folate deficiency Inflammation Inflammation ACE inhibitors ACE inhibitors Hyperparathyroidism – bone marrow fibrosis Hyperparathyroidism – bone marrow fibrosis Aluminium toxicity Aluminium toxicity Inadequate dialysis Inadequate dialysis Malignancies, including multiple myeloma Malignancies, including multiple myeloma

36 Iron studies Ferritin Ferritin Iron storage protein, giving an indirect measurement of stored iron Iron storage protein, giving an indirect measurement of stored iron ↓ ferritin always Iron def, but high in inflammation (inflammatory marker) ↓ ferritin always Iron def, but high in inflammation (inflammatory marker) Transferrin Transferrin Transports iron from stores to the bone marrow. Transports iron from stores to the bone marrow. Transferrin saturation Transferrin saturation Gives a measure of the iron available to bone marow Gives a measure of the iron available to bone marow Useful to detect functional iron deficiency Useful to detect functional iron deficiency

37 Iron Deficiency – definition TSAT< 20% TSAT< 20% Ferritin < 100ug/L (not on EPO) Ferritin < 100ug/L (not on EPO) Ferritin < 300ug/L ( on EPO) Ferritin < 300ug/L ( on EPO) Like to see ferritin around 600 Like to see ferritin around 600

38 Iron Supplementation Oral Oral Suboptimal,limited absorption,side effects Suboptimal,limited absorption,side effects IM IM Painful,discolouration,muscle sarcomas,variable absorption Painful,discolouration,muscle sarcomas,variable absorption IV IV Ideal. Single and maintenance dosing (500mgs) Ideal. Single and maintenance dosing (500mgs) Iron polymaltose Iron polymaltose Or Iron sucrose if polymaltose not tolerated Or Iron sucrose if polymaltose not tolerated

39 Iron Polymaltose Very well tolerated Very well tolerated Recent study (Dec 2008) in Australia showed of 503 infusions on 260 pts Recent study (Dec 2008) in Australia showed of 503 infusions on 260 pts No anaphylaxis No anaphylaxis 7 patients (2.7%) had some side effect (SE) 7 patients (2.7%) had some side effect (SE) 2 x urticaria – 2 nd infusion. Have since had further Tx with no SEs 2 x urticaria – 2 nd infusion. Have since had further Tx with no SEs 2 x nausea and vomiting – 1 st infusion. Re- challenged, again SE’s so changed to Iron sucrose. 2 x nausea and vomiting – 1 st infusion. Re- challenged, again SE’s so changed to Iron sucrose. 1 x nausea and itching – had previously had uneventful Tx – given Iron sucrose with no SEs 1 x nausea and itching – had previously had uneventful Tx – given Iron sucrose with no SEs 1 x hypotension – within 1 hour of 1 st infusion. Ceased then recommenced slower with no further problems. 1 x hypotension – within 1 hour of 1 st infusion. Ceased then recommenced slower with no further problems. 1 x burning sensation in neck, scalp and groin at 1 st infusion, has since had further Tx (at lower dose as on HD) with no SEs 1 x burning sensation in neck, scalp and groin at 1 st infusion, has since had further Tx (at lower dose as on HD) with no SEs

40 This recent Australian study, showed no anaphylactic reactions and only a small number with milder reactions such as n & v, rash and urticaria which resolved quickly. This recent Australian study, showed no anaphylactic reactions and only a small number with milder reactions such as n & v, rash and urticaria which resolved quickly.

41 Iron Infusion Iron Infusion Iron Infusion 500 mg Iron Polymaltose (Ferrosig) 500 mg Iron Polymaltose (Ferrosig) 5 x ampoules $30 ($6 ampoule) 5 x ampoules $30 ($6 ampoule) Iron Sucrose PBS listed (S100) $140 5 x ampoules Iron Sucrose PBS listed (S100) $140 5 x ampoules If on EPO, iron deficient and documented adverse reaction to polymaltose If on EPO, iron deficient and documented adverse reaction to polymaltose Aranesp Aranesp 100 mcg 4 x pre-filled syringe (1 x box) cost $ mcg 4 x pre-filled syringe (1 x box) cost $ mcg 4 x pre-filled syringes (1 x box) cost $ mcg 4 x pre-filled syringes (1 x box) cost $600

42 Given the cost of EPO to correct anaemia, it’s important to maintain adequate iron stores to optimise its response. Given the cost of EPO to correct anaemia, it’s important to maintain adequate iron stores to optimise its response.

43 Causes of iron deficiency ERT stimulates erythropoiesis and increases demand for iron ERT stimulates erythropoiesis and increases demand for iron Decreased iron absorption Decreased iron absorption Blood loss Blood loss Functional iron deficiency Functional iron deficiency

44 Iron deficiency in HD Exacerbated by blood loss Exacerbated by blood loss HD pts lose 2.5L blood each year HD pts lose 2.5L blood each year (1 – 3g of iron/yr) (1 – 3g of iron/yr) mg /wk replacement needed to offset loss mg /wk replacement needed to offset loss Pre ESRD and PD pts loose approximately 250 ml/yr Pre ESRD and PD pts loose approximately 250 ml/yr Further exacerbated by poor GI iron absorption Further exacerbated by poor GI iron absorption

45 Iron – CARI Guidelines 2005 Regular Assessment ( 3 monthly) at initiation of EPO therapy to maintain sufficient iron stores Regular Assessment ( 3 monthly) at initiation of EPO therapy to maintain sufficient iron stores Target Serum Ferritin 200 – 500 ug/L Target Serum Ferritin 200 – 500 ug/L TSAT 30 – 40% TSAT 30 – 40% Goal is for IV Fe to maintain target Hb without risk of iron overload Goal is for IV Fe to maintain target Hb without risk of iron overload Delay blood sampling after Iron infusion for 2 weeks as takes time to be absorbed (false low reading) Delay blood sampling after Iron infusion for 2 weeks as takes time to be absorbed (false low reading)

46 Anaemia and blood transfusions Please try to avoid! Please try to avoid! Hb < 80 g/L and symptomatic Hb < 80 g/L and symptomatic Blood transfusions expose patients to white blood cells in the transfusion which have human leucocyte antigens (HLA) on their surface. The patients then produce HLA antibodies - “sensitization” - making it more difficult to find a good donor match for a future kidney transplant. Blood transfusions expose patients to white blood cells in the transfusion which have human leucocyte antigens (HLA) on their surface. The patients then produce HLA antibodies - “sensitization” - making it more difficult to find a good donor match for a future kidney transplant. If transfusions are necessary then use a leucocyte filter. If transfusions are necessary then use a leucocyte filter. If you’re not sure who is on the list ask the renal GP If you’re not sure who is on the list ask the renal GP

47 Case Studies

48 Mr CA Age 60. Age 60. eGFR 55, creat 100 eGFR 55, creat 100 Hb 80 Hb 80 Iron studies; TSAT 12% Ferritin 100 Iron studies; TSAT 12% Ferritin 100 Mx? Mx?

49 Anaemia in CRF

50 Iron deficient BUT anaemia unlikely related to renal failure (anaemia usually once eGFR < 40) Iron deficient BUT anaemia unlikely related to renal failure (anaemia usually once eGFR < 40) Ix for other causes Ix for other causes ? Malignancy ? Malignancy GIT bleeding GIT bleeding

51 Similar to last case… Male in 50s. Male in 50s. Creat 140, eGFR 45 Creat 140, eGFR 45 Hb 100. Iron deficient anaemia. Hb 100. Iron deficient anaemia. LMO Mx LMO Mx EPO EPO Nil further investigations…. Nil further investigations…. Pt later diagnosed with Ca bowel Pt later diagnosed with Ca bowel

52 Ms PD 30 female. 30 female. On PD. Aranesp 20 mcg SC weekly On PD. Aranesp 20 mcg SC weekly eGFR 5, creat 500 eGFR 5, creat 500 Hb 80 MCV 70 Hb 80 MCV 70 Iron studies; TSAT % 11 Ferritin 100 Iron studies; TSAT % 11 Ferritin 100 Mx? Mx?

53 Iron deficient. Microcytic Anaemia. Iron deficient. Microcytic Anaemia. Rule out other causes then; Rule out other causes then; Correct Iron with IV Iron infusion (500mg APP) Correct Iron with IV Iron infusion (500mg APP) NB. Can give 1500 mg but in Kimberley stick to 500mg and aim to do regular (less change of adverse reaction with smaller dose) NB. Can give 1500 mg but in Kimberley stick to 500mg and aim to do regular (less change of adverse reaction with smaller dose) Re-check bloods. Once iron, B12 and folate OK, may need to increase EPO. Re-check bloods. Once iron, B12 and folate OK, may need to increase EPO.

54 Mrs PD 2 Same as last patient, except TSAT 30% ferritin 600 Same as last patient, except TSAT 30% ferritin 600 PD pt – poor compliance. Admitted to ED with APO/fluid overload PD pt – poor compliance. Admitted to ED with APO/fluid overload What part of FBC is also helpful? What part of FBC is also helpful? Htc – 0.15 Htc – 0.15 Haemodiluted Haemodiluted Repeated once adequate dialysis – Hb 95 Ht 0.4 Repeated once adequate dialysis – Hb 95 Ht 0.4

55 Moral of that story….. Don’t just treat a number Don’t just treat a number Treat the patient! Treat the patient! She needed full history and examination She needed full history and examination Important to remember, so as not to rush into blood transfusions etc. Important to remember, so as not to rush into blood transfusions etc.

56 Mr NY 54 male. On Aranesp 40mcg/fortnightly 54 male. On Aranesp 40mcg/fortnightly eGFR 25, creat 400 eGFR 25, creat 400 Hb 95 MCV 90 Htc 0.4 Hb 95 MCV 90 Htc 0.4 Iron studies; TSAT 40% Ferittin 600 Iron studies; TSAT 40% Ferittin 600 Mx? Mx?

57 Normochromic anaemia. Not iron deficient. Normochromic anaemia. Not iron deficient. Check all other parameters (folate, B12) Check all other parameters (folate, B12) Ensure no other cause for anaemia identified Ensure no other cause for anaemia identified May require increased EPO May require increased EPO Discuss with renal GP or Anaemia coordinator. Discuss with renal GP or Anaemia coordinator.

58 Ms AL 40 female. HD patient. 40 female. HD patient. eGFR 3, creat 200 On IV iron 100mg weekly at HD. On IV EPO (Eprex) units 3x wk eGFR 3, creat 200 On IV iron 100mg weekly at HD. On IV EPO (Eprex) units 3x wk Hb 60 Hb 60 Iron studies; Iron TSAT 30% ferritin 400 Iron studies; Iron TSAT 30% ferritin 400 Mx? Mx?

59 History History Hb 120 last month Hb 120 last month PV bleeding PV bleeding Examination Examination HR 120, BP 90/50 (usually 130/80) pale, feeling unwell. HR 120, BP 90/50 (usually 130/80) pale, feeling unwell. Management Management Send to hospital! Urgent. Needs Ix for anaemia and likely transfusion Send to hospital! Urgent. Needs Ix for anaemia and likely transfusion Transfuse through a leucocyte filter (to remove HLA Ag) Transfuse through a leucocyte filter (to remove HLA Ag)

60 Thank You!

61 References Jane York. Royal Perth Hospital. Anaemia Coordinator. Jane York. Royal Perth Hospital. Anaemia Coordinator. Iron polymaltose use in chronic kidney disease patients: one units experience. Anna Lee. Renal Society of Australia J 5(1) 5-8. December 2008 Iron polymaltose use in chronic kidney disease patients: one units experience. Anna Lee. Renal Society of Australia J 5(1) 5-8. December 2008 Renal Anaemia learning package. Catherine Hunter 2004 Renal Anaemia learning package. Catherine Hunter 2004 Managing anaemia in renal failure. Managing anaemia in renal failure. Oxford handbook of Clinical Medicine. 7 th Edition. Oxford Uni Press, Oxford handbook of Clinical Medicine. 7 th Edition. Oxford Uni Press, 2007.


Download ppt "Renal Anaemia Dr Anne Kleinitz KRSS GP. Why is this important? Anaemia is common in the Kimberley Anaemia is common in the Kimberley Multiple causes,"

Similar presentations


Ads by Google