A 54-year-old woman with end-stage renal disease secondary to diabetic nephropathy and hypertension comes to the office due to easy fatigability and tiredness. The patient experienced similar symptoms 6 months ago, but they improved after starting erythropoietin therapy for anemia. Over the past several weeks, the symptoms have recurred but she has had no chest pain, dyspnea, palpitations, syncope, melena, or hematochezia. The patient receives 3-4 hours of maintenance hemodialysis 3 times a week. She has no drug allergies.
Blood pressure is 130/78 mm Hg and pulse is 70/min with no orthostatic changes. She weighs 68 kg (150 lbs), which is her 'dry weight'. There are no heart murmurs. Abdominal examination shows no organomegaly and stool occult blood testing is negative.
Laboratory studies are as follows:

Hemoglobin was 8.2 g/dL and 10.1 g/dL 6 months and 4 months ago, respectively.
Which of the following is the most appropriate next step in management of this patient's anemia?

Question

A 54-year-old woman with end-stage renal disease secondary to diabetic nephropathy and hypertension comes to the office due to easy fatigability and tiredness.  The patient experienced similar symptoms 6 months ago, but they improved after starting erythropoietin therapy for anemia.  Over the past several weeks, the symptoms have recurred but she has had no chest pain, dyspnea, palpitations, syncope, melena, or hematochezia.  The patient receives 3-4 hours of maintenance hemodialysis 3 times a week.  She has no drug allergies.
Blood pressure is 130/78 mm Hg and pulse is 70/min with no orthostatic changes.  She weighs 68 kg (150 lbs), which is her 'dry weight'.  There are no heart murmurs.  Abdominal examination shows no organomegaly and stool occult blood testing is negative.
Laboratory studies are as follows:

Hemoglobin was 8.2 g/dL and 10.1 g/dL 6 months and 4 months ago, respectively.
Which of the following is the most appropriate next step in management of this patient's anemia?

Quizplus · Accepted Answer

11ec193a_98fb_d0fe_853d_c7c02967b195_MD0002_00 This patient initially had an appropriate response to erythropoietin-stimulating agent (ESA) therapy but now has worsening anemia. Iron deficiency is the most common cause of erythropoietin resistance. Patients with end-stage renal disease (ESRD) are at risk for iron deficiency due to: Absolute iron deficiency: Blood loss (eg, gastrointestinal, blood draws) or vigorous hematopoiesis during ESA therapyFunctional iron deficiency: Impaired mobilization of iron due to elevated hepcidin levels (ie, anemia of chronic disease) or because iron cannot be mobilized rapidly enough to keep up with hematopoiesis after ESA administration Absolute iron deficiency: Blood loss (eg, gastrointestinal, blood draws) or vigorous hematopoiesis during ESA therapy Absolute iron deficiency: Blood loss (eg, gastrointestinal, blood draws) or vigorous hematopoiesis during ESA therapy Functional iron deficiency: Impaired mobilization of iron due to elevated hepcidin levels (ie, anemia of chronic disease) or because iron cannot be mobilized rapidly enough to keep up with hematopoiesis after ESA administration Functional iron deficiency: Impaired mobilization of iron due to elevated hepcidin levels (ie, anemia of chronic disease) or because iron cannot be mobilized rapidly enough to keep up with hematopoiesis after ESA administration Normocytic anemia can be seen in the early stages of absolute iron deficiency (ie, before microcytosis develops) as well as in functional iron deficiency (ie, anemia of chronic disease), explaining this patient's normal mean corpuscular volume. The diagnosis of absolute iron deficiency in patients with chronic kidney disease (CKD) is complex and is commonly based on parameters such as low transferrin saturation (eg, ≤20%) and ferritin (eg, ≤200 ng/mL in hemodialysis patients) levels. All patients with ESRD on ESA therapy should be treated with iron, regardless of the results of iron studies, unless ferritin is >500 ng/mL. It is likely that this patient had limited iron stores that were rapidly depleted following initiation of ESA therapy. For completion, she should also be evaluated for gastrointestinal blood loss. (Choices B and D) Pure red blood cell aplasia is a hypoproliferative disorder that can be caused by anti-erythropoietin antibodies. Other hypoproliferative disorders (eg, myelodysplastic syndrome) can be diagnosed with bone marrow biopsy. However, hypoproliferative disorders are associated with increased serum iron levels due to reduced iron utilization. In addition, the brand of epoetin alfa most commonly associated with anti-erythropoietin antibodies has been removed from the market. Although bone marrow biopsy is the gold standard for diagnosis of absolute iron deficiency, parameters such as transferrin saturation and ferritin are commonly used to identify it in patients with CKD. (Choice C) Inadequate hemodialysis can cause ESA hyporesponsiveness, but this patient has maintained her dry weight and does not have symptoms of volume overload. (Choice E) Red blood cell transfusions come with significant risks (eg, volume overload, transfusion reaction) and are reserved for severe anemia (hemoglobin <7 g/dL) in patients unresponsive to ESAs after iron supplementation. Educational objective: Iron deficiency is the most common cause of erythropoietin resistance in patients with end-stage renal disease (ESRD). All patients with ESRD receiving erythropoietin-stimulating agents should be treated with iron, regardless of results of iron studies unless ferritin >500 ng/mL. __________ References: Pattern of resistance to erythropoietin-stimulating agents in chronic kidney disease. (http://www.ncbi.nlm.nih.gov/pubmed/21697809)

A 54-Year-Old Woman with End-Stage Renal Disease Secondary to Diabetic