Focus on... Anemia Management
Patients routinely failing to achieve and maintain hemoglobin levels of > or equal to 11gm/dL require the interventional skills of an adept clinician. The following areas of investigation should be considered for all patients failing to meet the CMS clinical performance measure goal for anemia management.
1. Inadequate Epogen dosage.
- Is dose less than 50-100 units/kg TIW?
- Have doses been missed or held? If hospitalized, has current Epogen order been communicated to acute unit?
- Are dose adjustments being made too frequently? Most experts agree on dose changes no more frequently than every 4-6 weeks.
2. Iron deficiency. This is the most common cause of hyporesponse. Iron stores must be sufficient to support new red cell formation.
- Is ferritin < 100?
- Is transferrin saturation <20%?
3. Blood loss.
- Is there known blood loss? Does access bleed excessively after needle removal? Do dialyzer and/or bloodlines clot frequently? Has patient undergone surgery?
- Are occult blood cards positive?
4. Infection/inflammation. Interferes with red cell production by: (1) releasing cytokines, which inhibit red cell precursors, and (2) impairing iron metabolism.
- Is ferritin increased while transferrin saturation is decreased?
- Is WBC count elevated?
5. Secondary hyperparathyroidism. Interferes with red cell production by
(1) directly inhibiting of red cell development, and (2) diminishing bone
marrow space due to marrow fibrosis
- Is parathyroid hormone level elevated?
6. Aluminum toxicity. Interferes with red cell production by (1) inhibiting
enzymes necessary for red cell growth, (2) interfering with iron transport,
and, (3) increasing fragility of red blood cells.
- Is aluminum level elevated?
7. Additional medical conditions
- Malignancy: impairs development of red blood cells/ destruction of red blood cells by chemotherapeutic agents
- AIDS: decreased production of red blood cells in bone marrow/ destruction of red cells by medications/ inadequate nutritional and vitamin stores for red cell production
8. Hemolysis. Exacerbates anemia by destroying mature red cells. Causes:
- Medications.
- Hypotonic and/or hyperthermic dialysate.
- Waterborne toxin(s).
- Chemicals such as bleach and formaldehyde.
- Defective blood tubing.
- Excessive negative pressure (arterial pressure more negative than —250 mm Hg).
9. Malnutrition. Thought to interfere with red cell production by (1) decreased protein levels lead brain to sense less need for oxygen and decrease hemoglobin production, and (2) decreased proteins available red cell formation.
- Is serum albumin low?
- Is serum pre-albumin low?
10. Vitamin deficiency. Water-soluble vitamins are lost during dialysis. Folate and B complex vitamins are necessary for red cell production.
- Is patient taking prescription B-complex vitamin?
- Does patient take vitamin in morning before dialysis?
While not all-inclusive, we hope this review will help spotlight potential problem areas and lead to better anemia management outcomes.
If additional clinical assistance is needed, please contact Network 8. We will be glad to assist you with your anemia management efforts.