Pass Medicine 24

Question 4 of 79   A 64 year old gentleman was seen in the renal patient clinic. He had a known history of polycystic kidneys and for the last nine months was undergoing haemodialysis. He complained of increasing shortness of breath on exertion over the last few weeks with a reduced appetite. He was assessed by his GP who undertook the following investigations: Results (16 weeks ago): Hb 9.6 g/dl Platelets 242 * 109/l WBC 6.6 * 109/l Ferritin 22 (NR 15-250 mcg/l) B12 322 (NR 160-900 ng/l) Folate 18 (NR 3-20 mcg/l) Na+ 136 mmol/l K+ 4.8 mmol/l Urea 22.2 mmol/l Creatinine 468 µmol/l Upper GI endoscopy: hiatus hernia seen Lower GI endoscopy: NAD He was subsequently commenced on ferrous sulphate 200mg TDS by his GP, but did not feel much better. His past medical history comprised diabetes mellitus, hypertension and hypercholesterolaemia for which he was prescribed aspirin 75mg OD, simvastatin 40mg ON, ramipril 5mg OD, amlodipine 5mg OD and glicliazide 80mg OD. Examination revealed the presence of a pale gentleman with a blood pressure of 132/78 mmHg, heart rate 82 bpm and respiratory rate of 18/min. Examination of his cardiovascular and respiratory systems revealed the presence of a JVP 3cm and an absence of pedal oedema with good air entry in all zones. Examination of his abdomen revealed the presence of two ballotable masses in the renal angle but otherwise no masses and auscultation was unremarkable. In this instance he therefore requires repletion of his iron stores prior to commencing erythropoietin therapy.2 mmol/l Creatinine 512 µmol/l TSH 1.Investigations undertaken at the clinic revealed the following results: Hb 10. there is no indication for a packed red cell transfusion here.6 mmol/l Urea 25. which require consideration. His iron stores remain deplete despite oral iron therapy. There are several causes of anaemia. . iron deficiency anaemia. See guidelines by The Renal Association for more information. malignancy as well as the usual causes of anaemia. Intravenous iron therapy is thus the most appropriate treatment option.1 g/dl Platelets 222 * 109/l WBC 7.2 mu/l What is the single next best management step? Continue oral iron therapy and recheck FBC. ferritin and transferrin saturation in four weeks Commence intravenous iron therapy Arrange referral to gastroenterology and haematology for further investigation Commence erythropoietin therapy Arrange packed red cell transfusion This gentleman has developed anaemia.2 * 109/l Ferritin 76 (NR 15-250 mcg/l) Transferrin saturation 18% B12 342 (NR 160-900 ng/l) Folate 17 (NR 3-20 mcg/l) Na+ 136 mmol/l K+ 4. a well recognised complication of chronic kidney disease. including erythropoietin deficiency. chronic inflammation. as indicated by a ferritin of less than 100 and a transferrin saturation of less than 20. 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 anorexia/nausea 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 . This is usually a normochromic normocytic anaemia and becomes apparent when the GFR is less than 35 ml/min (other causes of anaemia should be considered if the GFR is > 60 ml/min). Many patients. especially those on haemodialysis. Rate. correct and update the 'Chronic kidney disease: anaemia' notes Next question             . the most significant of which is reduced erythropoietin levels. 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'  Rate. discuss and give feedback on this question  Discuss.12 g/dl determination and optimisation of iron status should be carried out prior to the administration of erythropoiesis-stimulating agents (ESA). Anaemia in CKD predisposes to the development of left ventricular hypertrophy . discuss and give feedback on this question Next question  Chronic kidney disease: anaemia Patients with chronic kidney disease (CKD) may develop anaemia due to a variety of factors. .3% of users answered this question correctly Search Passmedicine Search term Go  Open MRCP Part 2 Written textbook (.H8QY3j8l.renal.org./review/textbook.Anaemia management in people with chronic kidney disease (CG114) The Renal Association (http:// http://www.org/guidelines/modules/anaemia-inckd#sthash.3% D 40.8% 35.co.3% C 6.Save my notes Question stats A 14.3% E 3.uk/guidance/CG114/chapter/1-Guidance)     2011 .google.dpbs) CKD anaemia guidelines Suggest a link Report a broken link  Google search on "Chronic kidney disease: anaemia" (https://www.php) External links NICE (http://www.nice.uk/#q=Chronic kidney disease: anaemia ) Dashboard .3% B 35. 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