CKD-anemia

Question 1

List the EPA drugs

Answer 1

epoeitin alfa: eprex
epoeitin beta: recormon
darbepoeitin
micera

Question 2

clinical presentation of anemia

Answer 2

• asymptomatic at first (lungs and heart compensate)
• SOB, lethargy, poor appetite conjunctival pallor

decreased O2 delivery to organs

Question 3

what Hgb levels are needed for anemia treatment

Answer 3

<10 g/dL

dont give to ppl with > 11g/dL if not greater risk of CVS complications
goal Hgb count is 10-11.5 g/dL
dont exceed >13g/dL

Question 4

goal levels of TSAT and serum ferritin

Answer 4

TSAT: > 20%
serum ferritin: >200 for HD, >100 non HD

Question 5

SE of ESA

Answer 5

• HTN (Not a contraindication unless uncontrolled)
• Vascular access thrombosis
• Seizures (?) ‒ Prior h/o of seizure is not a contraindication of ESA use
• Flu-like syndrome
• Reduced dialysis efficiency
• Pure red cell aplasia

but its generally well tolerated

Question 6

whats pure red cell aplasia

Answer 6

• development of neutralizing antibodies to ESAs and endogenous EPO
• Resulting in absolute resistance to therapy requiring blood transfusions
  - Need to discontinue therapy to prevent anaphylactic reactions
• Associated with SC admin of epoetin alfa (Eprex) and suboptimal storage/transport conditions

only after ruling out hyporesponsiveness/resistance to ESA then check for PRCA

Question 7

causes of hyporesponsiveness/resistance to ESA

Answer 7

• Iron deficiency (most common cause!)
• Hyperparathyroidism (direct bone marrow suppression)
• Inflammation/infection (impair delivery of Fe to bone marrow)
• Malignancies, chemotherapy, AIDS
• Malnutrition (substrate deficiencies); hypoalbuminemia
• blood loss, chronic bleeding, Al toxicity

Question 8

MOA of ESA

Answer 8

stimulate differentiation of erythroid progenitor stem cells and induce release of reticulocytes from bone marrow

Question 9

(initial) dosing of eprex

Answer 9

50-100 units/kg 3x/week IV

in singapore is IV only

Question 10

(initial) dosing of recormon

Answer 10

40 units/kg 3x/week IV or SC

Question 11

(initial) dose of darbepoetin alfa (aranesp)

Answer 11

0.45mcg/kg 1x per week IV or SC

PD: once every 2 weeks

longer half life can impreve pt compliance

Question 12

(initial) dose of micera

Answer 12

0.6 mcg/kg q2weeks IV or SC

PEGylated epoetin –> increases stability –> increases half life
less frequent administration can improve half life

Question 13

monitoring after administering ESA

when and monitor what

Answer 13

• measure Hgb every 2-4 weeks following initiation/dose change
• after stable monitoe every 3 months

Question 14

what to do if allergy/resistance to ESA

Answer 14

• use hypoxia inducible factor propyl hydroxylase inhibitors (HIF - PHIs)
• stimulate EPO transcription in kidneys and liver

Not recommended for non-dialysis CKD due to lack of long term safety

Question 15

dosage forms of iron spplementation

Answer 15

• PO (1st line)
• IV (in HD when PO is insufficient)
• Transfusion (last line)

Question 16

Dosing of PO iron

whats the daily dose and dosing instructions

Answer 16

• at least 200mg of Fe per day
• in 2-3 doses
• take away from food/medication

Question 17

DDI with oral Fe

Answer 17

• Ca salts –> impair Fe absorption
• Quinolones –> bind to Fe
• H2RA and PPI –> increases gut pH and impair absorption of Fe

Question 18

Names of IV Fe in sg

Answer 18

• iron sucrose (Venofer)
• Ferric carboxymaltose (Ferinject)

Question 19

SE of IV Fe

Answer 19

• allergy, hypotension, dizziness, dyspnea, lower back pain, heart palpitations, arthritis
• anaphylaxis (!!)
• Iron overload
• increased risk of infection

• anaphylaxis causes cvs and respi due to antibody production
• withold PO until 5-7 after IV iron administration