- Best estimate of target Hb in patients with CKD is 10-12mg/dL

- IV Iron should be used in patients on HD

- Iron gluconate/sucrose is safter than iron dextran

- Iron may worsen infection, do not want to especially give IV iron

- ESA's --> use in combo with iron replacement.  Use the lowest dose.  Continue through HTN.  Monitor for effects at least monthly, minimize use.

- Once a patient is at stage 5 they are almost always treated for anemia

- 80% of patients starting dialysis have anemia, quality of life is very low

- Low hemoglobin increases risk of CVD event or are associated with worse CV outcome

- If you spend more time at a lower hemoglobin level you have a higher risk

- If not treated there are related CVD risk factors

- Less fatigue and fewer fatigue sx

- Better physical well-being

- Better functional well-being

- Increased activity

- Maintained Hb levels

- Decrease LVH

- Decrease hospitilization, decreased mortality

- Excretory

- Metabolic

- Endocrine - Kidney is responsible for 9% of production of erythropoietin

- EPO is used to make RBC, if you decrease this you decrease RBC's, which increases PTH, which makes bone marrow unresponsive to other triggers

- blood loss/bleeding anywhere

- Hemolysis, decreased RBC lifespan

- Don't make ingredients B12, folate, iron EPO (Big one)

- Oral Iron agents (See Mirk's lecture?)

- IV:  Iron dextran, Sodium ferric gluconate, Iron Sucrose, Ferumoxytol

- ESA's:  IV or SQ (Epoetin alfa, Darbepoetin alfa)

- Low compliance with oral products, not great with severe cases anyway

- Adjunctive therapies such as L-carnitine, Ascorbic acid, and androgens are NOT proven to be effective, so stop buying them you dumbasses

Pros:  Efficacy, no absorption issues.  Patient adherence not a factor

Cons:  Time, patient needs to come into office, COST, Side effects, may worsen infections (iron is FOOD for bacteria, LOLZ)

Why use iron and ESA at the same time? 

ESA lowers the dosage requirement for Iron

- Monitor Iron Indices

TSAT - Transferrin saturation, which transfers iron around the body and is a good indicator of the amount of iron available at a particular time

Ferritin - If a patient has an infection or inflammation this level will increase -->  Not the greatest indicator but if it is low the patient definitely needs more iron. 

When to Monitor:  Initial ESA therapy - qmonth, once stable do q3months.  If on dialysis it will be qmonth as well

- Oldest IV iron

- Major side-effect is Anaphylaxis (~1%), may pretreat this with steroids, benadryl

- Give a test dose to see if rxn occurs

- Relatively low cost

- Comes in 100mg bottles

- Test does is called the INFeD dose.  Fatal rxns have occured following the INFeD dose as well as after a well tolerated INFeD and during therapy

- Lower risk of anaphylaxis than Iron Dextran

- More favorable side-effect profile

- Available as a 62.5mg ampule

- Least amount of anaphylactic reactions reported

- May still be OK for patients allergic to other iron salts

- Best side effect profile...well tolerated

- Available as a 100mg vial

- Look at iron indices, are they at goal?

- Repletion dosing, iron indices are too low, need to replenish

- Maintenance dosing, iron indices are adequate, need to maintain. 

- ESA is an Erythropoetin-stimulating agent

- Adding Iron to this therapy decreases dose of ESA required

- ESA's increase RBC production and lengthen lifespan of RBC

- Used to maintain Hb and prevent transfusions; changes in dose based upon Hb, with target concentration being 10-12mg/dL (or g?)

Effectiveness:  S/S anemia, Hb, Hb trends, need for transfusion

Safety:  ADR - use drug charts for comprehensive, Hb, Hb trends

ESA treatment should continue through HTN, occlusion, hx of seizure, decreased nutritional status

Dose adjust usually by ~25%

- Decrease if Hb approaches 12g/dL or Hb increase is >1g/dL over 2 weeks

- Increase dose if rise in Hb <2g/dL over 2 weeks, or if patient requires transfusion

- Chronic renal failure

- Cancer, shortened overall survival and/or increased tumor progression

*INCREASED MORTALITY, SERIOUS CARDIOVASCULAR EVENTS, THROMBOEMBOLIC EVENTS, STROKE and INCREASED RISK OF TUMOR PROGRESSION OR RECURRENCE *

- ESA, Epigen/Procrit

- SC or IV

- Short-acting ESA

- Usually dosed TIW

- Starting dose 50-100 units/kg

- ESA, Aranesp

- SC or IV

- Long-acting ESA, dosed q1-2 weeks

- Starting dose 0.45mcg/kg

- 1500 units of Epoetin is equivalent to about 6.25mcg of Darbepoetin

- Hemoglobin, TSAT, Ferritin

- "Normal" lab values are not the target lab values

Example:  Healthy adult male -->  Hb = 13.5-17.5g/dL

CKD Patient --> Hb = 10-12g/dL