This fairly fit 83 year old lady with a history of hypertension usually has an eGFR around 40. She is on lisinopril 10mg and furosemide 40mg (best tolerated combination, bendroflumethiazide did not have any effect on blood pressure) and her BP is well controlled on this combination at around 130/68 at her latest visit.
For several months she has had a haemoglobin of around 106 g/l. Her haematinics and blood indices are otherwise normal apart from a slightly low haematocrit of 0.32.
Is an eGFR of around 40 low enough to cause renal anaemia? She is only a little tired, are we best just to monitor things? Should I be looking for another cause for her anaemia?
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That haemoglobin is a little low for that eGFR, but it may be that you find no other cause. There is a big range of Hb values at any eGFR, including at end stage.
It is unusual to drop below 100g/l until eGFR is substantially less than 30, but she isn’t below 100. This level of renal impairment could be compounding another cause and look for deficiencies of haematinics and check a CRP as an indicator of inflammation.
Interestingly ACEi do worsen renal anaemia slightly. However the effect isn’t huge, if this is the best combination for her, she might prefer to tolerate the slightly lower Hb. Her current level of Hb is above the level at which guidelines would recommend commencing EPO therapy.
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Things to read:
- Edinburgh Renal Unit – GP Referral criteria
- Edinburgh Renal Unit – Renal Anaemia
- NICE Management of Anaemia in CKD – Anaemia in CKD
- Edinburgh renal Unit – Management of CKD
- SIGN Guideline on Management of Diabetes – SIGN CKD
- NICE CKD Guidelines – NICE CKD