Patient Encounter Part 2

The patient returns to your clinic 2 years later with complaints of "feeling tired all of the time." She had been trying to exercise more, but has not had enough energy to exercise for the past 6 months or so. She also complains that she feels cold all of the time, despite increasing the temperature in her house.

Current Meds: Furosemide 80 mg orally daily; lisinopril 40 mg orally daily; metopro-lol tartarate 50 mg orally twice daily; insulin glargine 25 units subcutaneously at bedtime; insulin lispro subcutaneously per sliding scale with meals

ROS: Slightly pale skin color; fatigue daily in the afternoon; otherwise unremarkable PE:

VS: BP 135/85 mm Hg, P 72 bpm, T 35.9°C (96.6°F); wt 79.5 kg (175 lb) Chest: RRR, normal Si, S2 present.

Abd: Obese; no organomegaly, bruits or tenderness, (+) bowel sounds; heme (-) stool

Exts: 1+ pedal edema bilaterally; decreased sensation in feet; small lesion on left ankle that appears to be healing slowly

Labs: Sodium 142 mEq/L (142 mmol/L); potassium 4.8 mEq/L (4.8 mmol/L); chloride 103 mEq/L (103 mmol/L); carbon dioxide 20 mEq/L (20 mmol/L); BUN 58 mg/ dL (20.71 mmol/L urea); SCr 3.2 mg/dL (283 pmol/L); glucose 130 mg/dL (7.28 mmol/L); white blood cell (WBC) count 4.8 x 103 cells/m3 (4.8 x 109/L); red blood cell (RBC) count 2.5 x 106 cells/m3 (2.5 x 1012/L); hemoglobin (Hgb) 8.0 g/dL (80 g/L or 4.96 mmol/L); hematocrit (Hct) 25% (0.25); platelets 250 x 103 cells/m3 (250 x 109/L); HbA1C 7.5% (0.075)

What signs and symptoms are consistent with anemia of CKD?

What additional information could you request to determine other causes of anemia in this patient?


General Approach to Therapy

Studies have demonstrated that initiation of treatment for anemia before stage 5 CKD decreases mortality in patients with ESKD receiving dialysis, particularly in the elderly.44 The treatment of anemia can decrease morbidity, increase exercise capacity and tolerance, and slow the progression of CKD if target Hgb levels are achieved.45

Patients with CKD should be evaluated for anemia when the GFR falls below 60 mL/min or if the SCr rises above 2 mg/dL (177 mmol/L). If the Hgb is less than 11 g/dL (110 g/L or 6.8 mmol/L), an anemia workup should be performed. The workup for anemia should rule out other potential causes for anemia (see Chap. 63). Abnormalities found during the anemia workup should be corrected before initiating erythropoiesis-stimulating agents (ESAs), particularly iron deficiency, as iron is an essential component of RBC production. If Hgb is still below the goal level when all other causes of anemia have been corrected, EPO deficiency should be assumed. EPO levels are not routinely measured and have little clinical significance in monitoring progression and treatment of anemia in patients with CKD.

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