1. Anemia in Hemodialysis 1

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3. Etiology The anemia of chronic kidney disease (CKD) is primarily due to insufficient production of the glycoprotein hormone erythropoietin (EPO). Although EPO can be produced in many of the body's tissues, EPO required for erythropoiesis is generally produced by endothelial cells in proximity to the renal tubules. 3

4. Symptoms Fatigue Dyspnea difficulty concentrating Dizziness sleep disorders cold intolerance Headaches Palpitation Hemostatic dysfunction Chest pain 4

5. TREATMENT 5

6. ERYTHROPOIETIN 6

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8. Erythropoietin Should be initiated in CKD patients when the hemoglobin falls below 10 g/dL. Target Hgb levels should generally be in the range of 11 to 12 g/dL. They also recommend that the Hgb target should not exceed 13 g/dL. 8

9. Erythropoietin Subcutaneous versus intravenous Initial dose: 4000 units 2-3 times per week 9

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11. Side effects Worsening of hypertension Seizures Graft clotting Hyperkalemia 11

12. Causes of decreased response Iron deficiency Hyperparathyroidism Inflammation and infection Inadequate dialysis Bleeding 12

13. Iron deficiency Depletion of iron stores Chronic blood loss Blood retention by the dialysis lines and filter Blood sampling for laboratory testing Accidents related to the vascular access Surgical blood loss Occult gastrointestinal bleeding Decreased dietary iron absorption Phosphate binders inhibit iron absorption Histamine-2 blockers, proton pump blockers, and functional achlorhydria impair iron absorption Uremic gut does not absorb iron optimally Increased iron demand Due to increased rate of erythropoiesis induced by erythropoiesis-stimulating agents Impaired release of iron from storage tissues (reticuloendothelial blockade) 13

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15. Iron testing should usually be delayed for 1 week after treatment with intravenous iron 15

16. Oral iron These supplements are associated with poor efficacy and troublesome side effects, such as constipation, dyspepsia, bloating, or diarrhea. Oral iron should not be used for most hemodialysis patients. For patients on peritoneal dialysis, oral iron is much more convenient than intravenous iron. 16

17. Intravenous iron Intravenous iron therapy has superior availability and efficacy when compared with oral iron therapy. 17

18. Red blood cell transfusions Transfusion of packed red cells should be used in severely anemic patients who are experiencing symptoms. 18

19. Nandrolone decanoate Androgens should not be used as an adjuvant to ESA therapy 19