Clinical Corner: Anemia of Chronic Kidney Disease

Articles

Anemia and Heart Failure: A Community Study (Shannon M. Dunlay, MD, Susan A. Weston, MS, Margaret M. Redfield, MD, Jill M. Killian, BS, Veronique L. Roger, MD, MPH, The American Journal of Medicine, August 2008)

Anemia: Its Impact on Hospitalizations and Length of Hospital Stay in Nursing Home and Community Older Adults (T.S. Dharmarajan, Anna Pankratov, Evelyn Morris, Saima Qurashi, Gregory Law, Sunila Phillips, Praveen Jaspal, Indira Donepudi, Edward P. Norkus, Journal of the American Medical Directors Association, May 2008)

Study of Anemia in Long-Term Care (SALT): Prevalence of Anemia and Risk of Falls in Nursing Home Residents 85 Years of Age and Older (Naushira Pandya, Brahim Bookhart, Gregory Reardon , Journal of the American Medical Directors Association, March 2008)

Anemia: It’s All About Quality of Life (David R.Thomas, Journal of the American Medical Directors Association, February 2007)

Once-Monthly Darbepoetin alfa for Maintaining Hemoglobin Levels in Older Patients With Chronic Kidney Disease. (Anil Agarwal, Marcia R. Silver, Michael Walczyk, Wei Liu, Paul Audhya, Journal of the American Medical Directors Association, February 2007)

Epidemiology of Chronic Kidney Disease and Anemia Bruce E. Robinson, Journal of the American Medical Directors Association, November 2006)

Practical Approach to the Diagnosis and Treatment of Anemia Associated With CKD in Elderly (Anil K. Agarwal, Journal of the American Medical Directors Association, November 2006)

Implications of Medicare Part D in CKD Anemia Treatment. (Richard G. Stefanacci, Journal of the American Medical Directors Association, November 2006)

Anemia Increase Risk for Falls in Hospitalized Older Adults: An Evaluation of Falls in 362 Hospitalized, Ambulatory, Long-Term Care, and Community Patients (T.S. Dharmarajan, Sai Avula, Edward P. Norkus, Journal of the American Medical Directors Association, June 2006)

Treatment of Kidney Disease and Anemia in Elderly, Long-Term Care Residents (Eric G. Tangalos, Jeffrey G. Hoggard, Anne M. Murray, David R. Thomas, Journal of the American Medical Directors Association, July 2004)

Anemia-Why It Is Important (Eric G. Tangalos)

Case Studies

1. Case 1 is that of an 87-year-old Caucasian man with heart disease and CKD who had resided in an LTC facility for 3 years and in whom random determination resulted in a hemoglobin level of 7.8 g/dL.
2. Case 2 is that of an 85-year-old Caucasian woman with Stage 4 CKD (30 to 59 mL/min) who was becoming reclusive, withdrawn, and inactive and was losing weight.
3. Case 3 is that of a 75-year-old Caucasian man in an assisted living facility who had three hospital admissions in the last month for worsening CHF, which prompted his admission to an LTC facility.
4. Case 4 is that of a thin, 79-year-old, African-American woman who was discharged to an LTC facility after hospital admission for a fall and pneumonia.
5. Case 5 is that of an 82-year-old Caucasian woman who was being transferred to an LTC facility for short-term rehabilitation owing to clinically significant functional decline after hospital treatment for mild CHF.
6. Case 6 was that of an 86-year-old Caucasian man who was able to propel himself around his LTC facility in a wheelchair, socialize, and feed himself but was becoming more short of breath, edematous, and anorexic.

Tables from the AMDA Anemia in the Long Term Care Setting Clinical Practice Guideline

Complications Associated With Anemia

Cardiac complications (e.g., congestive heart failure, left ventricular hypertrophy,30 myocardial infarction 22, 23) Cognitive impairment17,19,24 Depression31 Falls7, 9, 23, 25 Frailty32, 33 Impaired physical performance11, 32 Increased mortality6

Responsibilities of Selected Interdisciplinary Team Members in Recognizing Anemia

Lack of a consistent definition of anemia in the elderly Knowledge deficits concerning best practices in the assessment and management of anemia Lack of data on the outcomes of anemia treatment in the frail elderly Lack of research on anemia in the elderly long term care population

Suggested Components of a Noninvasive Laboratory Evaluation of Anemia

Complete blood count with reticulocyte count Examination of morphology by peripheral smear Ferritin, serum iron, total iron-binding capacity Serum folate and vitamin B12 Hepatic and renal function Sedimentation rate Serum protein electrophoresis Stool for occult blood Thyroid-stimulating hormone

Additional tables

• Common Causes and Diagnostic Criteria for Specific Types of Anemia
• Summary of Treatment Options for Specific Types of Anemia
• Stages of Chronic Kidney Disease³⁶
• Summary of NKF K/DOQI Guidelines on Using ESAs* to Treat Anemia Associated With CKD
• Suggested Laboratory Tests for Monitoring Response to Anemia Treatment