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• Discussion 2

Anemia affects more than 37 million Americans who have chronic kidney disease (CKD). According to U.S. Department of Health and Human Services (2020), approximately 1 out of every 7 people with CKD also suffer from anemia (U.S. Department of Health and Human Services, 2020). The kidneys play a vital role in producing erythropoietin (EPO), which is a hormone that signals bone marrow to make red blood cells. When a person’s kidneys are damaged, they produce less erythropoietin (EPO), fewer red blood cells, and less oxygen is delivered to the body’s organs and tissues. Other factors that can cause anemia are blood loss from dialysis, infection, inflammation, and malnutrition (U.S. Department of Health and Human Services, 2020).

To differentiate if the anemia is caused by iron deficiency or chronic disorders, transferrin can be requested. Transferrin is generally increased in iron deficiency anemia and decreased in anemia from chronic disorders. Patients with anemia of chronic disease do not generally have hemoglobin values below 9.5 g/dL. The total iron-binding capacity (TIBC), an indirect measurement of transferrin, is low in anemia of chronic disease because there is ample iron, but the iron is not easily available in the body. In some cases where both iron deficiency and anemia of chronic disease are possible, bone marrow aspiration with iron staining can be performed to distinguish between the two (Iron Disorders Institute, 2020). A blood transfusion would not be indicated in this patient. Indication for blood transfusion is hemoglobin levels lower than 7 or in cases of hemodynamic instability.

Medication recommendations for this patient include iron supplements, vitamins, and erythropoiesis-stimulating agents (ESAs). Iron supplements can be prescribed orally or given intravenously (IV) during dialysis. Vitamin supplements such as vitamin B12 or folate are suggested to facilitate healthy red blood cells. Ascorbic acid may be recommended to increase the absorption of iron supplements. ESAs can be given IV or subcutaneous to help stimulate the production of red blood cells in bone marrow (U.S. Department of Health and Human Services, 2020). Blood pressure should be closely monitored and controlled as needed during ESA treatment. Special consideration should be given to patients who are at risk for heart attack, stroke, heart failure, and cancer. ESAs increase the risk of venous thromboembolism, tumor growth, and iron overload (Cleveland Clinic, 2021).

Patients should receive education on pharmacological and non-pharmacological management of anemia. Measures such as adherence to diet, adequate medication management, laboratory testing and monitoring of kidney function should be expressed. Education on oral iron side effects should be provided. The patient should be advised that oral iron commonly causes gastrointestinal issues such as metallic taste, nausea, flatulence, constipation, diarrhea, and epigastric pain (Auerbach, 2021).

Monitoring of patients receiving iron replacement depends on the severity of anemia. Evaluation for patients on oral iron is recommended after two weeks of starting medication. The nurse practitioner should review hemoglobin and reticulocyte counts. For patients on IV iron, follow up is recommended four to eight weeks after administration (Auerbach, 2021). It is important for the advanced practice nurse (APN) to rule out any additional underlying conditions that may contribute to CKD anemia. Supportive care and management of symptoms is an important aspect to improving outcomes for patients suffering from CKD anemia.  

References

Auerbach, M. (2021). Treatment of iron deficiency anemia in adults. Uptodate. https://www.uptodate.com/contents/treatment-of-iron-deficiency-anemia-in-adults.

Cleveland Clinic. (2021). Erythropoietin-Stimulating agents.  https://my.clevelandclinic.org/health/drugs/14573-erythropoietin-stimulating-agents.

Iron Disorders Institute. (2020). Anemia of chronic disease. https://irondisorders.org/anemia-of-chronic-disease-2/.

U.S. Department of Health and Human Services. (2020). Anemia in chronic kidney disease. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/kidney-disease/anemia.