08 Aug discussion response
A 78-year-old female presents to the emergency room after a fall 3 days ago. She recently had a right above-the-knee amputation and was leaning over to pick something up when she fell. She did not want to come to the hospital, but she is having difficulty managing at home because of the pain in her left leg where she fell. Her patient medical history reveals right AKA, peripheral vascular disease, type 2 diabetes, and end stage 3 chronic kidney disease. Current medications include quinapril 20mg po daily, Lantus 30 units at bedtime, and Humalog to scale before meals. There are no known drug allergies. The physical exam is negative and x-rays reveal no acute injuries. Laboratory studies reveal a normal white blood cell count: Hgb of 8 and HCT of 24. The MCV is normal.
After a thorough history and physical examination, I would diagnose this patient with anemia in chronic kidney disease. Chronic kidney disease is diagnosed when there is evidence for more than 3 months of kidney damage and is characterized by accumulation of metabolic waste products in blood, electrolyte abnormalities, mineral and bone disorders, and anemia (Coyne, Goldsmith, & Macdougall, 2017).GFR is the best indicator for CKD, but an ultrasound will often show small kidneys with increased echogenicity. This patient has diabetes and peripheral vascular disease which puts her at risk for developing anemia in CKD. Depending on the stage of the CKD, clinical presentation varies, but common symptoms are generalized fatigue, nausea, anorexia, pruritis, sleep disturbance, smell and taste disturbance, hiccups, and seizures (Zadrazil & Horak, 2015).
Further evaluation of lab tests would be necessary. The following lab tests should be ordered BUN/creatinine or a complete metabolic profile as this will also get the GFR, urinalysis, urine for protein, iron profile, ferritin, vitamin b12, and erythropoietin level. Correcting the underlying cause of the anemia would depend on cause. The patient benefit from iron transfusions such as Injectafer weekly times 2 doses and dose would depend on her weight, if she is greater than 50kg then she would receive 750mg, if she is less than 50kg she would receive 15mg/kg, and then reevaluate the patients hemoglobin in about 56 days. This is when it should be at its highest (Injectafer, n.d.). Another choice would be venofer iron infusions. If the iron infusions did not bring the hemoglobin level up the patient should be prescribed Aranesp to increase their hemoglobin levels. Aranesp is an erythropoiesis-stimulating agent that is administered subcutaneously. Recommended starting dose for patients with CKD not on dialysis is 0.45mcg/kg subcutaneously every 4 weeks (Aranesp, n.d.). This patient’s hemoglobin should be monitored prior to every Aranesp injection and should be held if greater than 11. This patient will need education on diet and following a diabetic low salt diet. The patient should be counseled on the importance of controlling blood sugar levels and the role that diabetes can play in developing other chronic diseases. The patient should also have a nephrology consult to be evaluated. The patient’s history plays a huge part in diagnosis. The fact that the patient has diabetes and peripheral vascular disease places her at risk for anemia in CKD.
Differential Diagnosis:
Iron deficiency anemia: Iron deficiency anemia is an anemia resulting from inadequate iron supplementation or excessive blood loss (Camaschella, 2015). Workup would consist of a thorough history and physical and labs tests such as a cbc, iron profile, ferritin, and TIBC. Treatment would be with ferrous sulfate 325mg by mouth daily for at least six months. IF the patient does not tolerate the oral iron then peripheral iron infusions can be given to the patient.
Erythropoietin deficiency: Erythropoietin (EPO) is a hormone that plays an important role in the regulation of erythropoiesis and is mainly released from the kidneys in response to tissue hypoxia, and EPO’s primary action is to promote the proliferation and differentiation of the colony-forming unit-erythroid and other erythroid progenitor (Gowanlock, Sriram, M, Xenocostas, & Lazo-Langner, 2016). Thorough history and physical exam should be performed as well as lab tests such as cbc, erythropoietin level, iron profile, ferritin, and TIBC. Treatment would be with a medication such as Aranesp or Procrit injections.
B12 and folate deficiencies: B12 and folate deficiency is rather common in older adults due to inadequate intake of vitamin b12 and folate rich foods, and malabsorption (Green, 2017). A thorough history and physical would be necessary to help diagnose this patient. Labs would be cbc, vitamin b12 and folic acid level, iron profile, ferritin, and TIBC. Treatment would be vitamin b12 1000mcg IM for 7 days, then once a week for one month, and then monthly, or the patient could take oral vitamin b12 1000cmg daily.
References
Aranesp . (n.d.). https://www.pi.amgen.com/~/media/amgen/repositorysites/pi-amgen-com/aranesp/ckd/aranesp_pi_hcp_english.pdf
Camaschella, C. (2015, May 7). Iron-Deficiency Anemia. The New England Journal of Medicine, 372, 1832-1843. https://doi.org/10.1056/NEJMra1401038
Coyne, D., Goldsmith, D., & Macdougall, I. (2017, December). New options for the anemia of chronic kidney disease. Kidney International Supplements, 7(3), 157-163. https://doi.org/https://doi.org/10.1016/j.kisu.2017.09.002
Gowanlock, Z., Sriram, S., M, A., Xenocostas, A., & Lazo-Langner, A. (2016, June 16). Erythropoietin Levels in Elderly Patients with Anemia of Unknown Etiology. PLOS. Retrieved from https://doi.org/10.1371/journal.pone.0157279
Green, R. (2017). Vitamin B12 deficiency from the perspective of a practicing hematologist. Blood, 129, 2603-2611. https://doi.org/https://doi.org/10.1182/blood-2016-10-569186
Injectafer. (n.d.). https://injectafer.com/what-is-injectafer
Nakhoul, G., & Simon, J. (2016, August). Anemia of chronic kidney disease: Treat it, but not too aggressively. Cleveland Clinic Journal of Medicine, 83(8), 613-624. https://doi.org/10.3949/ccjm.83a.15065
Zadrazil, J., & Horak, P. (2015, June). Pathophysiology of anemia in chronic kidney diseases: A review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub, 159(2), 197-202. Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.865.3136&rep=rep1&type=pdf
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