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...of IV iron therapy at moderately elevated serum ferritin levels (Coyne et al., 2007) and the controversy erupting from recent studies surrounding erythropoiesis-stimulating agents (ESAs). Studies demonstrated increased risks when targeting higher hemoglobin (Hb) level with an ESA in patients with chronic kidney disease (CKD), evidence that conflicts with national anemia management guidelines published in 2006 (Drueke et al., 2006; National Kidney Foundation [NKF], 2006; Singh et al., 2006).
At this symposium, expert nephrology clinicians, including a nurse, physician assistant, and physician, discussed how a team approach to anemia management can be effective. The topics addressed included updating anemia practices, strategies for implementing a maintenance IV iron protocol to improve patient outcomes, and emerging information that encourages nurses and other health care providers to rethink the current anemia treatment philosophy. This article reports on the symposium highlights, as well as patient case studies and key questions posed by nurses and addressed by the faculty.
How Are We Doing and Can We Do Better? A Team Approach to Anemia Management
Andrea Easom, MA, MNSc, APN, BC, CNN-NP
Anemia is a common complication of advancing CKD and end stage renal disease (ESRD) and a key concern for nephrology professionals and providers (U.S. Renal Data System, 2006). The mounting controversy on targeting high Hb levels in patients has encouraged investigators to assess the current state of anemia management at the provider level and identify opportunities for improvement. Recent statistics report that the cumulative probability of an incident patient achieving an initial Hb of 11 g/dL was similar across large dialysis providers, with about 90% of patients reaching target by the third month after initiation of dialysis (Collins, Dunning, Zhang, & Gilbertson, 2006). This means that about 10% of patients are not achieving an Hb of 11 g/dL and suggests a need to assess current anemia protocols to improve outcomes.
Other patients frequently have Hb levels that exceed the United States Food and Drug Administration's (FDA) recommended upper limit of 12 g/dL. Data have shown that the cumulative probability of overshooting the target to an Hb of 14 g/dL within 6 months of initiation after achieving a first Hb of 11 g/dL ranged from 10% to 50% across large dialysis providers (Collins et al., 2006). Given that overshooting practices may be a safety concern, clinicians should assess the design of their protocols if their patients continually have Hb levels above target. Many protocols greatly increase the ESA dose if the Hb drops below 11 g/dL. Although a large increase in ESA requirements can quickly get the patient into target, it is important to start reducing the ESA dose when the patient is trending up in order to avoid overshooting targets. Overshooting can lead to holding ESA doses and start a seesawing effect of the patient's Hb level. Patients have better outcomes when their Hb levels are stable and have the worst outcomes when their Hb levels fluctuate (Besarab, 2006; Fishbane & Berns, 2005).
An anemia management protocol that balances ESA therapy with maintenance IV iron can stabilize Hb levels and avoid the use of inappropriately high ESA doses (Besarab, 2006). Iron loss is a major problem in patients on hemodialysis and can markedly reduce the effectiveness of ESA therapy (Sargent & Acchiardo, 2004). Ongoing iron losses can occur from blood lost during dialysis-related procedures, such as routine blood sampling, dialyzer clotting, blood left in the circuit, and postdialysis bleeding. IV iron administered on a regular basis can help compensate for the effects of continued blood and iron loss. Accordingly, nurses need to look beyond the Hb levels and evaluate the whole patient, including iron status, to improve individual outcomes as well as the unit's overall outcomes.
Evaluating the Whole Patient
Data from the ESRD Clinical Performance Measures (CPM) Project has identified certain patient characteristics and clinical parameters that have a significant role in anemia management. For example, patients dialyzing for greater than 6 months are more likely to achieve an Hb level of 11 g/dL or greater than incident patients (86% vs 64%, respectively); patients dialyzed with an arteriovenous graft or fistula are more likely to reach an Hb level of 11 g/dL or greater than those dialyzed with a catheter (87% vs 85% vs 76%, respectively); and patients with a higher serum albumin (greater than 3.5 g/dL) are more likely to achieve an Hb level of 11 g/dL or greater than malnourished patients (87% vs 65%, respectively) (Centers for Medicare & Medicaid Services, 2005). It is important to be attentive to malnourished patients because they may be iron depleted. These patients often get large quantities of ESA and no iron because malnutrition can interfere with the reliability of certain diagnostic tests for iron deficiency.
The total iron-binding capacity (TIBC) marker, regularly obtained as part of iron studies to guide iron administration, has been shown to correlate with nutritional status. This is important because TIBC, in conjunction with serum iron, is used to calculate the percentage of transferrin that is saturated with iron (Kalantar-Zadeh et al., 1998). Transferrin is the iron-carrying protein that transports iron in the circulation to the muscle, the bone marrow for erythropoiesis, and the reticuloendothelial cells for storage (Andrews, 1999; Fishbane & Maesaka, 1997). The transferrin saturation (TSAT) level represents the amount of iron circulating in the body, thereby providing an estimate of iron immediately available for erythropoiesis (Petroff, 2005).
Studies have demonstrated that as malnutrition worsens, the TIBC value decreases, a situation that results in a falsely elevated TSAT level (Kalantar-Zadeh et al., 1998). (Note: TSAT is a calculated percentage so that alterations in the values used in the calculation will affect the TSAT and may skew the results.) For example, in the author's experience, a malnourished patient with a serum iron level of 40 mcg/dL and a TIBC level below 200 mcg/dL can have a TSAT of 27%, which is a sufficient TSAT level because it is above 20%. However, when the TIBC is less than 200 mcg/dL, the TSAT in this patient may be falsely elevated due to malnutrition and the actual TSAT is probably lower. This patient may benefit from iron administration. Conversely, if a patient has a TIBC above 200 mcg/dL, the clinician can be confident that the TSAT is accurate. Investigators have recommended against using the TSAT ratio as a diagnostic tool if serum TIBC is less than 200 mcg/dL (Kalantar-Zadeh et al., 1998).
Malnutrition also has been shown to interfere with the reliability of the serum ferritin marker (Kalantar-Zadeh, Rodriguez, & Humphreys, 2004). Serum ferritin is an indirect measure of storage iron and contains little, if any, iron. During...
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