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A 42 year old is brought into renal clinic by his wife reporting progressing fatigue and malaise over the past

3 months He has an underlying diagnosis of sarcoidosis with renal involvement diagnosed on renal biopsy

and is monitored by the renal team every 3 months Over the past 2 years his renal function has

progressively deteriorated The patient continues to pass urine but does not currently undergo renal

replacement therapy On examination his heart sounds are unremarkable with no added sounds his chest

is clear His blood tests are as follows (blood results from 3 months ago in brackets)

WCC 76 10 l (62)

Hb 62 gdl (90)

MCV 85 fl (86)

Urea 17 (15)

Creatinine 190 micromoll (177)

K+ 53 mmoll (52)

Ferritin 33 microgl

Transferrin saturation (TSAT) 29

B12 normal

Folate normal

A venous blood gas demonstrates a pH 729

What is the most appropriate next treatment

Haemofiltration

Urgent referral for haemodialysis

Oral iron

Intravenous iron

EPO

Question 4 of 40

9



The patient has iron deficiency most likely related to chronic renal disease He has no acute indications for

haemofiltration with no pulmonary oedema hyperkalaemia or metabolic acidosis less than 725 In

addition his creatinine has worsened but is not yet a candidate for renal replacement therapy The latest

guidelines from KDIGO 2012 recommend adequate replacement of iron B12 and folate stores before

erythropoietin stimulating agents (ESA) in order to maximise benefit and prevent ESA resistance The

patients folate and B12 are adequate Iron deficiency in chronic renal disease patients are defined as TSAT

less than 20 and ferritin less than 20 microgL which this patients iron stores are above As a result EPOwould be most appropriate in this patient to treat his symptoms likely secondary to anaemia secondary to

chronic renal disease

Chronic kidney disease anaemia

Patients with chronic kidney disease (CKD) may develop anaemia due to a variety of factors the most

significant of which is reduced erythropoietin levels This is usually a normochromic normocytic anaemia

and becomes apparent when the GFR is less than 35 mlmin (other causes of anaemia should be

considered if the GFR is gt 60 mlmin) Anaemia in CKD predisposes to the development of left ventricular

hypertrophy - associated with a three fold increase in mortality in renal patients

Causes of anaemia in renal failure

reduced erythropoietin levels - the most significant factor

reduced erythropoiesis due to toxic effects of uraemia on bone marrow

reduced absorption of iron

anorexianausea due to uraemia

reduced red cell survival (especially in haemodialysis)

blood loss due to capillary fragility and poor platelet function

stress ulceration leading to chronic blood loss

Management

the 2011 NICE guidelines suggest a target haemoglobin of 10 - 12 gdl

determination and optimisation of iron status should be carried out prior to the administration of

erythropoiesis-stimulating agents (ESA) Many patients especially those on haemodialysis will

require IV iron

ESAs such as erythropoietin and darbepoetin should be used in those who are likely to benefit in

terms of quality of life and physical function

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External links

NICE (httpwwwniceorgukguidanceCG114chapter1-Guidance)

2011 - Anaemia management in people with chronic kidney disease (CG114)

The Renal Association (http httpwwwrenalorgguidelinesmodulesanaemia-in-

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The patient has iron deficiency most likely related to chronic renal disease He has no acute indications for

haemofiltration with no pulmonary oedema hyperkalaemia or metabolic acidosis less than 725 In

addition his creatinine has worsened but is not yet a candidate for renal replacement therapy The latest

guidelines from KDIGO 2012 recommend adequate replacement of iron B12 and folate stores before

erythropoietin stimulating agents (ESA) in order to maximise benefit and prevent ESA resistance The

patients folate and B12 are adequate Iron deficiency in chronic renal disease patients are defined as TSAT

less than 20 and ferritin less than 20 microgL which this patients iron stores are above As a result EPOwould be most appropriate in this patient to treat his symptoms likely secondary to anaemia secondary to

chronic renal disease

Chronic kidney disease anaemia

Patients with chronic kidney disease (CKD) may develop anaemia due to a variety of factors the most

significant of which is reduced erythropoietin levels This is usually a normochromic normocytic anaemia

and becomes apparent when the GFR is less than 35 mlmin (other causes of anaemia should be

considered if the GFR is gt 60 mlmin) Anaemia in CKD predisposes to the development of left ventricular

hypertrophy - associated with a three fold increase in mortality in renal patients

Causes of anaemia in renal failure

reduced erythropoietin levels - the most significant factor

reduced erythropoiesis due to toxic effects of uraemia on bone marrow

reduced absorption of iron

anorexianausea due to uraemia

reduced red cell survival (especially in haemodialysis)

blood loss due to capillary fragility and poor platelet function

stress ulceration leading to chronic blood loss

Management

the 2011 NICE guidelines suggest a target haemoglobin of 10 - 12 gdl

determination and optimisation of iron status should be carried out prior to the administration of

erythropoiesis-stimulating agents (ESA) Many patients especially those on haemodialysis will

require IV iron

ESAs such as erythropoietin and darbepoetin should be used in those who are likely to benefit in

terms of quality of life and physical function


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Question stats

A 56

B 9

C 111

D 456

E 287


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anaemia )

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Question stats

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C 111

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Search term







anaemia )

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Overall score 25

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anaemia )

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Overall score 25

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