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anemia of chronic renal failure

Anemia almost always accompanies uremia, with the degree of anemia roughly paralleling the degree of azotemia. A diagnosis of exclusion [2] Pathology: 1) diminished erythropoietin levels 2) compensatory mechanisms a) redistribution of blood flow b) increased affinity of hemoglobin for oxygen 3) increased iron losses, decreased iron absorption, increased hepcidin due to inflammation lead to iron deficiency [10] Clinical manifestations: - patients tend to tolerate marked anemia fairly well Laboratory: 1) serum chemistries - serum creatinine & eGFR; chronic renal failure stage 3* & higher [8] - serum erythropoietin levels decreased - not useful for diagnosis or management [2] 2) complete blood count (CBC) a) Hgb levels generally ~ 10 g/dL, but as low as 4 g/dL b) MCV is generally normal c) leukocyte & platelet count are unaffected 3) peripheral smear a) normochromia b) normocytic c) burr cells in 1/3 of patients 4) absolute reticulocyte count is low to low normal [2] 5) serum iron levels may be low [10] see pathology (above) 6) serum ferritin, TIBC, serum vitamin B12, serum folate, fecal occult blood for exclusion * ref [8] does not specify stage 3a vs 3b Management: 1) treatment of underlying renal disease 2) correct iron deficiency prior to epoetin or darbipoetin [9] - IV iron if oral iron does not correct iron deficiency [6,7] - blood transfusions are frequently needed - a trial of oral iron is indicated if transferrin saturation is <= 30% or the serum ferritin <= 500 mg/dL according to (NEJM) [9] 3) erythropoiesis-stimulating agent (epoetin) a) symptomatic anemia of chronic renal failure with blood Hgb < 10 g/dL [2] b) goal is hemoglobin >= 11.0 g/dL [2] - higher incidence of death, myocardial infarction, hospitalization for heart failure or stroke when target is 13.0 g/dL [2] c) generally effective (95%) d) suboptimal response may occur secondary to - iron deficiency, vitamin B12 deficiency or folate deficiency - myelofibrosis secondary to hyperparathyroidism e) darbipoetin is an effective alternative f) do not check serum erythropoietin [2] - erythropoietin indictate even if serum level normal [8] 4) other causes of anemia are often superimposed

Interactions

disease interactions

General

anemia of chronic disease (ACD)

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1733-34
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018, 2022. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Singh AK et al, Correction of anemia with epoeitin alpha in chronic kidney disease. N Engl J Med. 2006, 355:2085 PMID: 17108343 - Drueke TB et al, Normalization of hemoglobin level in patients with chronic kidney disease and anemia N Engl J Med. 2006, 355:2071 PMID: 17108342 - Drueke TB Anemia treatment in patients with chronic kidney disease. N Engl J Med. 2013 Jan 24;368(4):387-9 PMID: 23343068 - Remuzzi G and Ingelfinger JR Correction of anemia - Payoffs and problems N Engl J Med. 2006, 355:2144 PMID: 17108347
  4. Fishbane S, Nissenson AR. Anemia management in chronic kidney disease. Kidney Int Suppl. 2010 Aug;(117):S3-9 PMID: 20671741
  5. Kliger AS, Foley RN, Goldfarb DS et al KDOQI US commentary on the 2012 KDIGO Clinical Practice Guideline for Anemia in CKD. Am J Kidney Dis. 2013 Nov;62(5):849-59. PMID: 23891356
  6. Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
  7. Ribeiro S, Belo L, Reis F, Santos-Silva A. Iron therapy in chronic kidney disease: Recent changes, benefits and risks. Blood Rev. 2016 Jan;30(1):65-72. Review. PMID: 26342303
  8. NEJM Knowledge+ Hematology
  9. NEJM Knowledge+ Nephrology/Urology
  10. Ganz T, Nemeth E. Iron Balance and the Role of Hepcidin in Chronic Kidney Disease. Semin Nephrol. 2016 Mar;36(2):87-93. PMID: 27236128 Free PMC article. Review.