CKD Anemia

12, 13

Anemia is defined as:

Hbg

Annually

If a patient is stage G3, how often should they test for anemia?

Twice a year

If a patient is stage G4, how often should they test for anemia?

q 3 months

If patient is stage G5, how often should they test for anemia?

Iron Deficient Anemia

What type of anemia occurs when you have LOW ferritin and LOW TSAT?

Functional Iron Deficiency

What type of anemia occurs when you have HIGH/NORMAL Ferritin and LOW TSAT?

500, 30

People with anemia and CKD G5HD recommend to start iron if:

Ferritin

False

(True/False) In CKD G5HD, Oral Iron is recommended as first line treatment?

100, 40, 100-300, 25

People with anemia and NOT on dialysis OR CKD G5PD recommend to start iron if:

Ferritin

700, 40

Reasonable to withold iron treatment if Ferritin >_______ OR TSAT >______%

1-3 months

How often should you test Hgb, ferritin and TSAT if CKD G5HD?

Every 3 months

How often should you test Hgb, ferritin and TSAT if CKD G5PD?

200mg/d

What is the recommended daily elemental PO iron dose?

GI upset

What is the most common ADR of Oral Iron

H2 blockers, Antacids, Milk

List three things that can decrease the absorption of iron

Methyldopa/Levodopa, Fluoroquinolones, Penicillin, Tetracyclines

Name 4 medication classes that Iron can decrease the absorption of...

IV

Does IV or PO iron have a better increase in Hgb?

LMW Iron Dextran (INFed)

Which IV Iron requires an initial dose and has a BBW of increasing risk of anaphylactic-type reactions

Sodium Ferric Gluconate Complex (Ferrlecit)

Which IV iron is approved for iron deficiency in HD when recieving EPO therapy?

Ferumoxytol (Feraheme)

Which IV Iron has a BBW of fatal and serous hypersensitivity reactions?

Yes

If the you have addressed correctable causes of anemia and the patient is recieving dialysis, do you start ESA therapy?

11.5

What is the Hbg goal of ESA Therapy?

ESA Initiation should be individualized... consider QOL

If the you have addressed correctable causes of anemia and the patient is NOT recieving dialysis, do you start ESA therapy?

q 2-4 weeks

After starting ESA therapy, how often do you want to check Hbg before reaching maintenance dosing?

Pure Red Blood Cell Aplasia

What is a decrease in RBC precursors in bone marrow which can lead to SEVERE anemia?

False

(True/False) It is ok to continue ESA therapy during Pure RBC Aplasia

HIF-PIF (Hypoxia-inducible Factor-Prolyl Hydroxylase Inhibitor)

Pure RBC Aplasia -> STOP ESA -> Possibly use this medication as a secondary option after not responding to ESAs

Daprodustat (Jesduvroq) and Vadadustat (Vafseo)

Name the two HIF-PIF medication options

False (d/c after 3-4 months)

(True/False) HIF-PIFs should be trialed for at least 6 months prior to discontinuing if desired response is not achieved

True

(True/False) NEVER use ESAs and HIF-PIFs together

Blood Transfusions

This is the LAST possible option for anemia + CKD if treatment not working

True

(True/False) Blood transfusions should be avoided if the patient has the option to do an organ transplant

Infections, Iron overload, volume overload, coagulopathy, hyperkalemia, immune reactions

List some of the RISKS of Blood Transfusions

Maintain O2 carrying capacity and improving anemia symptoms

List 2 of the benefits of Blood Transfusions

If ESA or HIF-PIF failed or was harmful

At what point would the benefits outweigh the risks of blood transfusions

True

(True/False) When deciding if a blood transfusion if the correct choice, one should evaluate only symptoms and NOT Hgb thresholds.

False

(True/False) ACEi are contraindicated in the treatment of anemia and must be d/c'd immediately due to decreasing erythropoietin

True

(True/False) When initial tests do not reveal the cause, consider expanding the panel to potentially identify underlying causes as warranted based on the scenario

6-12 weeks

How long should one trial oral Iron

9-10

People with anemia and CKD G5D recieving HD/PD, recommend starting ESA therapy when

Hgb is

Epoetin Alfa (Epogen, Procrit)

Which ESA should be avoiding if on PD due to 3x/wk dosing not being realistic

4 weeks

Avoid adjusting ESA dosing more that once every ____________ (Except when Hgb increases >1 g/dL in 2-4 weeks after starting, then reduce dose 25-50%)

B

A patient with CKD G4 has Hgb 9.2 g/dL, ferritin 45 ng/mL and TSAT 15%. What is the most appropriate action?

A. Start IV Iron

B. Start Oral Iron

C. Start ESA therapy

D. Transfuse 1 unit RBC

C

Which of the following patients should stop IV iron therapy?

A. Ferritin 65, TSAT 15%

B. Ferritin 250, TSAT 25%

C. Ferritin 650, TSAT 50%

D. Ferritin 120, TSAT 18%

A

In CKD G5D patient on HD with Ferritin 220, TSAT 28% and Hgb 8.7 g/dL who has been on IV iron, what is the most appropriate next step?

A. Continue IV iron + start Darbepoetin

B. Increase IV Iron only

C. RBC Transfusion

D. Stop iron and wait

C

A CKD G4 patient on Darbepoetin has Hgb rise to 12.2 g/dL. What is the most appropriate action?

A. Continue same dose

B. Increase Darbopoetin

C. Reduce/hold Darbepoetin

D. Stop iron therapy

C

How often should TSAT and ferritin be monitored in CKD non-HD patient on weekly iron

A. Weekly

B. Monthy

C. q 3 months

D. Annually

2-4 weeks

AFter starting or adjusting ESA therapy, how often should Hgb be checked?

C

A patient on PD develops abdominal pain and cloudy effluent. What is the most appropriate empiric treatment?

A. IV Vanco + IV Cefepime

B. PO Ciprofloxacin

C. IP Vanco + Ceftazidime

D. SQ ceftriaxone

No

A patient has uncontrolled HTN, can you use ESAs in this patient?

Vadadustat

Which HIF-PHI agent can cause a rise in liver enzymes

C

At what hemoglobin level should ESA therapy be initiated in hemodialysis patients (CKD G5D)?

A. Always start regardless of Hgb

B. ≤ 10-11 g/dL

C. ≤9.0-10.0 g/dL

D. Never start ESA therapy

C

According to KDIGO, what is the recommended hemoglobin (Hgb) target when using ESAs in adults with CKD?

A. Normalize Hgb to >13 g/dL

B. Maintain Hgb 10-12 g/dL

C. Below 11.5 g/dL

D. Any increase above baseline

True

(True/False) If after three months of trying PO Iron it doesn't work, switch to IV iron

TSAT and Ferritin

After Iron therapy, which labs should be monitored?

B

History: 65-year-old female with stage 5 CKD on hemodialysis, previously treated with IV iron.

Labs: eGFR = 8 Hgb 8.7 g/dL TSAT 40% Ferritin 550 ng/mL

What is the next best step for anemia treatment?

A. Continue IV iron sucrose (Venofer)

B. Start epoetin alfa (Epogen) or darbepoetin (Aranesp)

C. Add oral ferrous sulfate daily

D. RBC transfusion

B

What is the primary goal of ESA therapy?

A. Normalize Hgb to >13 g/dL

B. Reduce transfusion needs, Hgb to below 11.5 g/dL

C. Eliminate fatigue entirely

D. Any increase above baseline

B

How often should hemoglobin be checked after initiating ESA?

A. Weekly

B. Every 2-4 weeks

C. Every 3 months

D. Only if symptomatic

C ( **ifs its greater than 11.5, decrease dose... if its greater than 12... hold dose ** d/c and hold are the same thing... D could also be considered/argued correct)

History: 72-year-old male with CKD on ESA (darbepoetin 40 mcg SC q2weeks) recently transitioned to peritoneal dialysis.

Labs: Hgb 12.2 g/dL Ferritin 300 ng/mL TSAT 28%

What adjustment is most appropriate for his ESA?

A. Increase darbepoetin dose

B. Continue same dose

C. Reduce darbepoetin dose

D. Discontinue ESA immediately

B

What risk is associated with overtreatment with ESAs (Hgb > 11.5)?

A. Hypoglycemia

B. Myocardial infarction or stroke

C. Severe pruritus

D. Neuropathy