A 50-year-old woman presents to the office with complaints of excessive fatigue and shortness of breath after activity, which is abnormal for her. The woman has a history of congestive heart failure with decreased kidney function within the last year. The woman appears unusually tired and slightly pale. Additional history and examination rules out worsening heart failure, acute illness, and worsening kidney disease. The CBC results indicate hemoglobin is 9.5 g/dL, which is a new finding, and the hematocrit is 29%. Previous hemoglobin levels have been 11 to 13g/dL. The patient’s vital signs are temperature 98.7°F, heart rate 92 bpm, respirations 28 breaths per minute, and blood pressure 138/72. The practitioner suspects the low hemoglobin level is related to the decline in kidney function and begins to address treatment related to the condition. Discuss the following:
Which test(s) should be performed to determine whether the anemia is related to chronic disease or iron deficiency, and what would those results show?
Should the practitioner consider a blood transfusion for this patient? Explain your answer.
Which medication(s) should be considered for this patient?
What considerations should the practitioner include in the care of the patient if erythropoietic agents are used for treatment?
What follow-up should the practitioner recommend for the patient?
Addressing Anemia in a Patient with Chronic Kidney Disease
This patient’s presentation, with new-onset anemia coinciding with declining kidney function, strongly suggests anemia of chronic disease (ACD).
Here’s a breakdown of the necessary steps:
1. Determining the Cause of Anemia:
Tests to Perform:
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Serum Iron: Measures the amount of iron circulating in the blood. In iron deficiency anemia, serum iron is low. However, in ACD, serum iron is often normal or even elevated due to iron being trapped in macrophages.
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Total Iron Binding Capacity (TIBC): Measures the blood’s capacity to bind iron. In iron deficiency anemia, TIBC is high due to low iron saturation. In ACD, TIBC is often normal or low.
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Ferritin: A storage protein for iron. In iron deficiency anemia, ferritin is low. In ACD, ferritin is often normal or elevated.
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Reticulocyte Count: Measures the number of immature red blood cells. This helps assess the bone marrow’s ability to produce new red blood cells. In iron deficiency anemia, reticulocyte count is low. In ACD, it may be normal or slightly elevated.
Expected Results:
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ACD: Serum iron and TIBC will likely be normal or low. Ferritin levels may be normal or elevated. Reticulocyte count may be normal or slightly elevated.
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Iron Deficiency: Serum iron and ferritin will be low. TIBC will be high. Reticulocyte count will be low.
2. Blood Transfusion:
Considering Blood Transfusion:
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Hemoglobin Levels: Blood transfusions are generally not recommended for ACD unless the patient is experiencing severe symptoms like heart failure, unstable angina, or severe shortness of breath. This patient’s hemoglobin is 9.5 g/dL, which is mildly low, but may not require immediate transfusion.
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Underlying Cause: Addressing the underlying cause of anemia, which is the chronic kidney disease, is the primary goal. Transfusion is a temporary solution and doesn’t address the root cause.
Addressing Anemia in a Patient with Chronic Kidney Disease
This patient’s presentation, with new-onset anemia coinciding with declining kidney function, strongly suggests anemia of chronic disease (ACD).
Here’s a breakdown of the necessary steps:
1. Determining the Cause of Anemia:
Tests to Perform:
-
Serum Iron: Measures the amount of iron circulating in the blood. In iron deficiency anemia, serum iron is low. However, in ACD, serum iron is often normal or even elevated due to iron being trapped in macrophages.
-
Total Iron Binding Capacity (TIBC): Measures the blood’s capacity to bind iron. In iron deficiency anemia, TIBC is high due to low iron saturation. In ACD, TIBC is often normal or low.
-
Ferritin: A storage protein for iron. In iron deficiency anemia, ferritin is low. In ACD, ferritin is often normal or elevated.
-
Reticulocyte Count: Measures the number of immature red blood cells. This helps assess the bone marrow’s ability to produce new red blood cells. In iron deficiency anemia, reticulocyte count is low. In ACD, it may be normal or slightly elevated.
Expected Results:
-
ACD: Serum iron and TIBC will likely be normal or low. Ferritin levels may be normal or elevated. Reticulocyte count may be normal or slightly elevated.
-
Iron Deficiency: Serum iron and ferritin will be low. TIBC will be high. Reticulocyte count will be low.
2. Blood Transfusion:
Considering Blood Transfusion:
-
Hemoglobin Levels: Blood transfusions are generally not recommended for ACD unless the patient is experiencing severe symptoms like heart failure, unstable angina, or severe shortness of breath. This patient’s hemoglobin is 9.5 g/dL, which is mildly low, but may not require immediate transfusion.
-
Underlying Cause: Addressing the underlying cause of anemia, which is the chronic kidney disease, is the primary goal. Transfusion is a temporary solution and doesn’t address the root cause.
