A 56-year-old man comes to the office due to fatigue. He has a 20-year history of diabetes mellitus treated with daily insulin therapy. The patient also has end-stage renal disease and receives hemodialysis 3 times a week. He has been receiving erythropoietin therapy for anemia (pretreatment hemoglobin: 8.0 g/dL). Physical examination shows pale conjunctiva. Laboratory results are as follows: Which of the following is the most appropriate intervention to improve this patient's symptoms?

Question

A 56-year-old man comes to the office due to fatigue.  He has a 20-year history of diabetes mellitus treated with daily insulin therapy.  The patient also has end-stage renal disease and receives hemodialysis 3 times a week.  He has been receiving erythropoietin therapy for anemia (pretreatment hemoglobin: 8.0 g/dL).  Physical examination shows pale conjunctiva.  Laboratory results are as follows:  Which of the following is the most appropriate intervention to improve this patient's symptoms?

Quizplus · Accepted Answer

Patients with advanced chronic kidney disease and end-stage renal disease frequently develop a hypoproliferative (normochromic, normocytic) anemia due to decreased erythropoietin production by the failing kidneys. The primary treatment is erythropoiesis-stimulating agents (ESAs), such as erythropoietin or darbepoetin, which increase production of red blood cells in the bone marrow. Goal hemoglobin is typically 10-11.5 g/dL. However, this patient has a hypochromic (low mean corpuscular hemoglobin concentration) and microcytic (low mean corpuscular volume) anemia that has not responded to ESA therapy. This suggests concurrent iron deficiency, which is the most common cause of inadequate response to ESAs in patients on dialysis. Iron stores can be rapidly depleted during hematopoiesis after ESA administration, especially in chronically ill patients whose iron stores may already be low. Iron stores should therefore be evaluated prior to starting ESAs and frequently thereafter. The treatment of choice for iron deficiency in patients on dialysis is intravenous iron. (Choice A) Blood transfusions are associated with significant complications (eg, volume overload, transfusion reactions) and should be used only for more severe anemia that cannot be corrected by other means. Iron supplementation in this patient is likely to restore responsiveness to ESAs and correct his anemia. (Choice B) Darbepoetin is an ESA with a longer half-life than erythropoietin and can be dosed less frequently; however, they both have the same effects on hematopoiesis. Both require sufficient iron stores to induce red blood cell production. (Choice C) Folic acid supplementation is beneficial for folate deficiency and hereditary spherocytosis. Folate deficiency causes a macrocytic anemia, not a microcytic anemia as seen in this patient. (Choice E) Tight blood glucose control decreases the incidence of microvascular complications of diabetes (eg, retinopathy, neuropathy, nephropathy). Although improved glucose control could reduce this patient's risk of renal complications, it will not help his anemia. Educational objective: Anemia of chronic kidney disease is due to erythropoietin deficiency; treatment is with erythropoiesis-stimulating agents (ESAs) (eg, erythropoietin, darbepoetin). Iron deficiency is the most common cause of inadequate response to ESAs in patients on dialysis. References: Erythropoiesis-stimulating agent hyporesponsiveness in end-stage renal disease patients. (http://www.ncbi.nlm.nih.gov/pubmed/26023017)

A 56-Year-Old Man Comes to the Office Due to Fatigue