Management

Anemias in Renal Disease The degree of anemia in patients with chronic kidney disease (CKD) can vary greatly; however, in general, patients do not become severely anemic until the glomerular filtration rate (GFR) is less than 30 mL/min/1.73 m² (Fishbane & Spinowitz, 2018). The symptoms of anemia may be the most troubling of the patient's symptoms. In patients with CKD, anemia contributes to increased cardiac output, reduced oxygen utilization, decreased cognition and ability to concentrate, reduced immune responsiveness, and reduced libido. Anemia may be more severe in patients with both CKD and diabetes (Fishbane & Spinowitz, 2018). Anemia in patients with CKD is discussed in Chapter 48. Anemia of Inflammation Anemia of inflammation describes anemia associated with chronic diseases including inflammation, infection, and malignancy. This classification was previously known as anemia of chronic disease (Weiss, Ganz, & Goodnough, 2019). This classification also includes anemia of critical illness that can develop within days after the onset of serious illness, and the anemia associated with aging. Many chronic inflammatory diseases are associated with normochromic, normocytic anemia (i.e., RBCs are of normal color and size). These disorders include rheumatoid arthritis, chronic infections, and many cancers. It is important that the underlying condition be identified so that it can be treated appropriately. The anemia of inflammation is usually mild to moderate and not progressive. The hemoglobin level does not usually fall below 9 g/dL and bone marrow samples have normal cellularity and normal stores of iron. Erythropoietin levels are low and iron use is blocked by erythroid cells (cells that are or will become mature RBCs). Erythrocyte survival may also be shortened. Many patients with anemia of inflammation have few symptoms related to their anemia and do not require treatment. Treatment of the underlying disorder allows iron stored in the bone marrow to be utilized, promoting increased RBC production and facilitating the rise of hemoglobin levels. Iron supplementation is not beneficial for these patients. Gerontologic Considerations Evidence suggests that inflammation may have a significant role in the development of anemia in older adults (Price, 2019). Higher-than-normal levels of inflammatory cytokines are found in older adults, and this pro- inflammatory state may predispose older adults to frailty. Frailty is manifested by weight loss, impaired mobility, generalized weakness, and loss of balance