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Last Updated 04/13/08

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Anemia is a common complication of end-stage renal disease (ESRD). Anemia occurs when there is a shortage of red blood cells or when the red blood cells are not correctly formed. In dialysis units, anemia is usually measured by the hematocrit blood test, which reports the percentage of the blood that is comprised of red blood cells. Normally, a hematocrit is from 37% to 47% for women and from 42% to 52% for men. Without interventions, a dialysis patient's hematocrit usually stabilizes between 20-25%. At this level, most patients tire easily and feel drained of energy. Several statistical analyses have shown that dialysis patients have signficantly more complications, hospitalizations, and a higher mortality rate when their hematocrit is below 30% (approximately).

Dialysis patients experience anemia (low hematocrit) primarily because their kidneys no longer produce adequate amounts of erythropoietin (EPO). EPO is the principal factor that stimulates red blood cell production in the bone marrow.

Before 1990, most dialysis patients experienced moderate to severe anemia on a long-term basis. At that time, dialysis patients were given frequent blood transfusions which also exposed them to possible infection by bloodborne pathogens such as hepatitis viruses and HIV. Today, thanks to the availability of bioengineered EPO, the need for most transfusions has been eliminated.

With most patients now routinely receiving EPO during their dialysis treatments, hematocrits are routinely in the range of 30-36%. The NKF-DOQI recommended target hematocrit range for dialysis patients currently is 33% to 36%. Most insurance companies and Medicare will not reimburse the dialysis facilities for EPO injections when the patient's hematocrit is above a certain number (36% approximately).

The production of healthy blood cells is also dependent on the body having enough iron, vitamin B12, folic acid and other substances. If a patient does not respond to EPO therapy, the most likely cause is a deficiency of iron. For this reason, most dialysis centers routinely monitor iron levels in the blood.

Warning:  Changes should never be made in a patient's treatment or care based solely on the information found here.  Every patient has unique healthcare concerns and considerations and all these factors must all be taken into account before any changes can be safely made.  All medical and therapeutic decisions must come from a qualified health care provider.  Read RenalWEB's Legal Disclaimer before proceeding.


  NEWS & LATEST ARTICLES
Roche appeals preliminary anemia drug injunction - article from Reuters - April 9, 2008
Thrombosis with Erythropoietic Stimulating Agents—Does Iron-Deficient Erythropoiesis Play a Role? - abstract from Seminars in Dialysis - April 6, 2008
NKF: Synthetic Erythopoiesis Stimulator Shows Promise in Early Study - article from MedPage Today - April 4, 2008
Affymax anemia drug shows promise in small study - article from Reuters - April 3, 2008
The Effect of Altitude on Dosing and Response to Erythropoietin in ESRD - abstract from the Journal of the American Society of Nephrology - April 2, 2008
Anemia Drugs' Marketing in Congressional Crosshairs - article from MedPage Today - April 1, 2008
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  ESSENTIALS AND CLASSICS
Anemia Management quality improvement from The Renal Network (ESRD Network 9/10) web page
The KDOQI™ Clinical Practice Guidelines And Clinical Practice Recommendations for Treating Anemia in Patients With Chronic Kidney Disease: Implications for Nurses (pdf) article from the Nephrology Nursing Journal
Anemia Fact Sheet (pdf format requires Adobe Acrobat reader.) from the American Nephrology Nurses’ Association
C-Reactive Protein and Anemia: Implications for Patients on Dialysis (pdf) article from the Nephrology Nursing Journal
Infection and Inflammation in Patients on Dialysis: An Underlying Contributor to Anemia and Epoetin alfa Hyporesponse (pdf) article from the Nephrology Nursing Journal
Adjusting IV Iron and EPO Doses in Patients on Hemodialysis Prior to Surgery: Can We Protect Our Patients From Iron-Deficiency Anemia? (pdf) article from the Nephrology Nursing Journal
The Challenges of Using Serum Ferritin to Guide IV Iron Treatment Practices in Patients on Hemodialysis With Anemia (pdf) article from the Nephrology Nursing Journal
Using CQI Strategies to Improve and Simplify IV Iron and Anemia Management:A Dialysis Facility’s Experience - on-line CEU from the ANNA web site - (on-line test expires: 10/20/2007) - full text pdf article
FDA Video on Patient Safety Topics: Erythropoietic Agents and Antibody-Mediated Anemias - from the U. S. Food and Drug Administration (FDA) - May 2006
Iron Management: A Clinical Perspective on Iron Parameters ceu from The National Kidney Foundation (NKF)
Iron Supplementation in Hemodialysis - Practical Clinical Guidelines (pdf format requires Adobe Acrobat reader) from Nephrology Dialysis Transplantation (NDT) - October 1998
Updating Practices in an Evolving IV Iron and Anemia Environment: Practical Solutions - (pdf) article from Nephrology Nursing Journal - September/October 2007
What You Need to Know About Anemia and Chronic Kidney Disease (pdf) pamphlet from The National Kidney Foundation (NKF)
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  WEB RESOURCES
Latest Scientific Journal Articles on Anemia - list compiled by RenalWEB's Journal Watch
Anemia LifeLine™ - The Anemia LifeLine™ educational initiative was created to help improve the lives of millions of Americans who suffer from anemia associated with many common, serious diseases.
Anemia and Chronic Kidney Disease - (pdf) from the National Kidney Foundation (NKF) web site
Anemia, EPO, kidney failure—and you from the Home Dialysis Central web site
Anemia in children with chronic kidney disease - full-text educational feature from Pediatric Nephrology - February 2008
Anemia: Mobilizing Resources for Positive Outcomes - (pdf) from the Kidney Learning System web site
Anaemia Nurse Specialist Association+ - UK web site
Be Active web site from Ortho Biotech Products, L.P.
Just the Facts: Anemia and Información esencial: Anemia (pdf format requires Adobe Acrobat Reader) from the Life Options web site
Morbidity and Mortality in Patients on Dialysis: The Impact of Hemoglobin Levels from the American Nephrology Nurses Association web site
National Anemia Action Council (NAAC) web site
Hyporesponse to Epoetin alfa: Patients at Risk Case Study of the Anemic Patient (pdf format requires Adobe Acrobat reader) - from the Nephrology Nursing Journal Educational Supplements - February 2002
Dialysis Facility Compare - Medicare's comparison of the quality of care that is provided at dialysis facilities throughout the United States and its territories includes information on anemia management
Drug and Supplements Info: Epoetin and Iron from National Library of Medicine MedLine Plus   
Erythropoietin Claims Monitoring Policy: Implications for Clinical Practice - a related on-line continuing education program from the American Nephrology Nurses Association (ANNA)
Revisions to the EPO/ Aranesp Monitoring Policy (pdf) from the Centers for Medicare and Medicaid Services (CMS)
Teaming Up for Peak Performance: Early Identification and Optimal Management of CKD-Related Anemia (pdf) free on-line CE program from the National Kidney Foundation (NKF) web site
Understanding Anemia in Kidney Disease from the AAKP web site
CMS's ESRD Clinical Performance Measures (CPM) Project
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  PUBMED SEARCHES (National Library of Medicine's MEDLINE Database)
anemia AND dialysis   Continually Updated!
EPO AND dialysis   Continually Updated!
MEDLINE / Pubmed Information from the National Library of Medicine
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  K/DOQI™ -  Kidney Disease Outcomes Quality Initiative

Anemia Management - Clinical Practice Guidelines for the Treatment of Anemia of Chronic Renal Failure (Table of Contents)

  1. Anemia Work-up
  2. Target Hematocrit/Hemoglobin
  3. Iron Support
  4. Administration of Epoetin
  5. Inadequate Epoetin Response
  6. Role of Red Blood Cell Transfusions
  7. Possible Adverse Effects Related to Epoetin Therapy
K/DOQI Home Page from the National Kidney Foundation web site
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  DISCUSSION FORUM
General Dialysis Nursing Issues and Questions (No dedicated RenalWEB forum yet for this topic)
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  PRODUCTS
Full prescribing information from Otho Biotech's web site for Procrit® (epoetin alpha) (pdf format requires Adobe Acrobat Reader)
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  INPUT / SUGGESTIONS
E-mail to RenalWEB on the Adequate Hematocrit Topic
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