Anaemia, heart failure and CKD (21)

This elderly man has multiple medical problems.  His main current problem is heart failure – he has moderate LV dysfunction, valvular heart disease and pulmonary hypertension.  He is seen by the Heart Failure Nurse and we have reached the point where we agree his treatment is palliative.  He gets recurrent peripheral oedema and ascites.  His renal function shows a urea of around 20 and creatinine of around 200.  At home he is able to walk with a frame from his bedroom to the living room but this makes him breathless.  He is a type 2 diabetic and also has mild memory impairment.

He has had a chronic long standing anaemia over a number of years.  This has seen his haemoglobin slide from the 10.3 down to 8.3 when last checked.   He had GI investigations and was found to have a number of polyps and an area of angiodysplasia.  He has had a couple of transfusions.  It was decided earlier this year that further investigation was not appropriate.  He is on iron so it is difficult to know how much of his anaemia is due to his renal problems.

When discharged last week it was suggested that we should contact you about erythropoietin treatment.  Improvement of his anaemia might help his heart failure a little though I suspect this would only be temporary.  He is very frail and clinic attendance might not be possible.  I would be grateful for your advice

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Current medications include: bumetanide 5mg OD, metolazone 2.5mg once weekly and insulin.

 

 

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There are 2 issues here:

1. Anaemia & EPO – the advice given to you is a bit misleading.  EPO is designed to bring haemoglobin up slowly, the recommended rise being 1gm/month.  In other words, he’s going to get decent haemoglobin in about 2-3 months time.  Furthermore, EPO is contraindicated in GI bleeding and his anaemia is probably mainly due to angiodysplasia rather than renal disease.  I would normally commit someone like this to regular transfusion.

2. Oedema – I would try and dry him out and ignore his U&Es.  Our ability to control heart failure is so often hampered by our worrying about the urea rising but I would ignore it.

 

 

 


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Anaemia and CKD III (20)

This diabetic lady has CKD3 with microalbuminuria of 14.8.  She was recently seen in the haematology clinic regarding her chronic anaemia (most recent haemoglobin was 100g/l).  She was in hospital at the end of last year when she was transfused and started on oral iron.  At that time endoscopy was normal but she has previously had angiodysplasia.  Haematology felt this is most likely anaemia of chronic disease rather than iron deficiency anaemia, and that it probably relates to her deteriorating renal function.  Her most recent eGFR was 52, creatinine 91 and urea 8.6.  They have suggested that she might be a candidate for EPO injections to boost her blood count.  I wonder if I should be referring her to renal clinic?

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B12 and folate are normal.  Ferritin 85, Transferrin saturations 17%

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Renal anaemia with a GFR above 30ml/min is extremely unusual indeed.  10% of anaemia in CKD 3 is explained by EPO-deficiency, but the patients involved are in the eGFR of 30-35 bracket, rather than 52 as in this case.  Given the history of previous angiodysplasia this is most likely the explanation for the recurrent anaemia.


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Anaemia and CKD in the frail elderly (19)

This rather frail 85 year old man has recently become anaemic.  His haemoglobin has dropped down to around 9.0 having previously been around the 11 mark.  Haematinics are normal.  His latest renal function shows urea 15.6, creatinine 213, potassium 4.8 and eGFR 26.

His general health is poor.  He lives at home and is slowly mobile with a zimmer but has had falls and is awaiting a residential or nursing home placement.

Can we attribute his anaemia to his CKD and should he be considered for EPO?  Or should we refer him to haematology for further assessment of his anaemia?

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Co-morbidities include: recent significant stroke, diabetes, angina, Parkinson’s disease, atrial fibrillation, hypertension and LVF.

 Currently: ACR 155, PCR 260, Ferritin 60.

12 months ago: Hb 10.5, urea 11.4, creatinine 168, ACR 120, PCR 185

3 years ago: ACR 35

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This gentleman has evidence of progressive CKD – now Stage 4 – almost certainly secondary to diabetic nephropathy given the longstanding albuminuria and proteinuria.  His anaemia has been evident for some time.  His haematinics do indicate that he may be Fe deficient – his ferritin is only 60 (we would normally look for a minimum of 100). His iron saturation has not been done but should be >20%.   I would suggest in the first instance repeat of his iron stores specifically to include iron saturation and ferritin.  If they are below targets then I would suggest oral iron supplementation.

 I don’t think there is a good indication for a renal clinic referral, but he may be a candidate for erythropoietin therapy if he remains anaemic when iron stores are replete.

 

 


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Anaemia in CKD (11)

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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