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Chapter 19: Anemia and Chronic Kidney Disease

A 68-year-old white male patient with a 35-year history of type 2 diabetes and known CKD stage 3 (serum creatinine 2.5 mg/dL, eGFR 35 cc/min) comes for his routine clinic visit. His renal function remains stable but you notice his previously stable hemoglobin has decreased from approximately 11–7.8 g. Your next steps are

A. Evaluate a complete CBC.

B. Order an iron panel (serum iron, TIBC, and ferritin).

C. Check for GI occult blood loss.

D. All of the above.

The answer is D. This patient’s CKD does not explain the significant drop in hemoglobin and the reader should be cognitive of coexisting etiologies of anemia in CKD patients. Specifically in this patient the higher likelihood of a GI malignancy resulting in blood loss and iron deficient anemia in addition to the relatively mild (hemoglobin 11 g) anemia of CKD.

In the management of patients with established CKD and anemia you should:

A. Treat all patient with hemoglobin greater than 12 g females or greater than 14 g males.

B. Only treat “symptomatic” patients irrespective of their hemoglobin levels.

C. Treat patients to a target hemoglobin level of 11–12 g.

D. None of the above.

The answer is D. Given the results of CHOIR & CREATE the FDA has specifically recommended caution in both the initiation and anemia therapy (Hbg <10 g) and the avoidance of “targets.” Management of anemia rather should focus on transfusion avoidance.

A 45-year-old obese, African–American female patient with CKD stage 4, secondary to poorly controlled hypertension and ASHD presents with slowly progressive anemia measured at today clinic visit at hemoglobin 7.5 g. She complains of fatigue and increased SOB even though she is clinically euvolemic. In anticipation of starting ESA therapy you have measured her iron studies (all normal), but notice today a chronic nonhealing 4 cm non-healing ulcer on her left lower extremity due to chronic venous insufficiency. She tells you she is under the care of a vascular surgeon. Your next steps are

A. Since the iron studies are normal and she has symptomatic anemia-initiate ESA therapy.

B. She has an active inflammatory process and you should avoid ESA therapy and wait until her ulcer heals.

C. Order a blood transfusion.

The answer is C. This is a difficult case as she has progressive anemia due to her CKD and also ...

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