Anemia: am I the only one who thinks it's all complicated?

LiverpoolJane · Jan 8, 2010

I'm a UK nurse so I'm more familiar with Hb as opposed to HCT, so please bear with me. I work in renal and our CKD patients tend to function well on a lower Hb than you or I. The fact that her HCT has dropped can be due to a number of factors, you say she has had an infection recently, was the drop after this? If she was admitted to hospital and have IV fluids? I tend to see some of our (mostly older) patients are chronically underhydrated and therefore their blood is haemoconcentrated, then given IV fluids can make their Hb look worse. Is or was her WCC high - while it is the RCC will drop - again, to be expected. If she is asymptomatic and I'm assuming if she is in LTC not running in any marathons, then she will cope with a lower Hb. We aim for a Hb of 11g/dL and use EPO in CKD non dialysis patients and you have already checked her iron profile which is in normal limits. If you have excuded any active bleeding I would re-check her CBC and whatever marker you use in the US for infection/inflammation and see if she responds over the next few weeks.

cupcake231 · Jan 8, 2010

I recommend researching the different types of anemia (because there are many) and try to fully understand how each is abnormal. This will help you understand what certain levels of certain things are characteristic of each type.

:) Best of luck!

morte, LPN, LVN · Jan 8, 2010

The attending MD is involved for the most part. He is on vacation right now, so in the meantime I'm doing some investigation so to speak. I definately will need a more experienced person to help me. If the patient needs something like Procrit or B12 injections, etc. I would not feel comfortable initiating something like that.

you can do B12 po, on an empty stomache.....but it is wise to check out folate as well, one will obscure the other.....

BmoreCRNP · Jan 9, 2010

you can do B12 po, on an empty stomache.....but it is wise to check out folate as well, one will obscure the other.....

I've noticed, for whatever reason, they don't use PO B12 in the nursing home. I know that unless someone is missing the intrinsic factor in the intestine there's no reason they shouldn't be able to take PO B12 for a deficiency. My personal opinion is that the B12 shot is easier for the nursing home because they just worry about it once a month rather than having to give someone yet another pill to take daily.

BmoreCRNP · Jan 9, 2010

I'm a UK nurse so I'm more familiar with Hb as opposed to HCT, so please bear with me. I work in renal and our CKD patients tend to function well on a lower Hb than you or I. The fact that her HCT has dropped can be due to a number of factors, you say she has had an infection recently, was the drop after this? If she was admitted to hospital and have IV fluids? I tend to see some of our (mostly older) patients are chronically underhydrated and therefore their blood is haemoconcentrated, then given IV fluids can make their Hb look worse. Is or was her WCC high - while it is the RCC will drop - again, to be expected. If she is asymptomatic and I'm assuming if she is in LTC not running in any marathons, then she will cope with a lower Hb. We aim for a Hb of 11g/dL and use EPO in CKD non dialysis patients and you have already checked her iron profile which is in normal limits. If you have excuded any active bleeding I would re-check her CBC and whatever marker you use in the US for infection/inflammation and see if she responds over the next few weeks.

I rechecked it twice after she came back from the hospital just to make sure. Another reason I think it's the kidneys is because along with the falling H&H, her K+ has gone up and I had to give her Kayexalate for that. Also her GFR dropped. Now it could also be that the acute illness made the kidney disease a little worse for the time being. I'll probably have to repeat the BMP as well to see if the renal failure is indeed getting worse, or if it was just the acute illness making it temporarily worse. I hope I'm making sense. Anyway, her PMD will be back Monday and I'm going to see what he says.

globalRN · Jan 13, 2010

pretty much what others have mentioned

another note look at the retic count and peripheral smear

if it is normochromic , normocytic

iron studies: show low ironbinding capacity

you need to do some thinking

because shouldn't be blindly putting people on iron...iron is an oxidizing agent.

for work up I do: CBCD, tsh, b12, folate, retic, peripheral smear, ferritin and iron studies

If you think there is ? hemolysis: Ld, ALT, Bili, haptoglobin, direct coombs test(DAT)

then there is always the fecal occult blood x 3.

before u order FOB: always ask what would you do if it is positive.

If patient is 97 years old, debilitated, demented, poor surgical risk....why do FOB

R U gonna prep the poor old patient for a colonoscopy when they aren't likely to get chemo or surgery? Of course, if you have obvious GI bleeding....possibly different if you

are hoping to stop the bleeding via GI intervention.

littleredmare · Jan 13, 2010

If you are suspecting B12 def check a 'MMA' methylmelonic acid-better indicator of

B12 def. Most people who are B12 def got there in the first place because they do not absorb or do not have the intrinsic factor (in stomach) to synthesize B12, or are vegans and don't get a lot of it from food. So unlikely to absorb it by mouth, injections and also Nascobal the nasal spray are good in that was, I think injection is cheaper 32cents?

I LOVE anemia. love love it. I need to keep my day job too!

A lot of hospitals will have a basic panel for anemia-I wouldn't get carried away first off with all the direct coombs etc-those are VERY expensive tests and if someone gets a bill they might not be happy about that one. I'd start with a ferritin, tibc, transferrin sat, B12, MMA, folate, and EPO level and take it from there...sounds like she's anemic from CKD, or a lot of elderly people have some MDS of one form or another...Depends on how farm you want to dig for trrouble!

morte, LPN, LVN · Jan 13, 2010

yes, the MMA is better than the direct B12, which isnt saying too much,lol....i have read recently that there is better B12 testing coming; from outside the country though, so dont know when..... and PO will work for most person, the key is LARGE dose, up to 5000 mcg, and on empty stomache, passive assimilation. But in long term care, they may prefer the inj, because that is chargeable (as far as i know). Some persons have trouble with cyano- and need methyl-.

wowza · Jan 13, 2010

This is not medical advice:

First is she still menstrual? The most likely cause of dropping hemoglobin in a pre-menopausal woman is having her period, especially if she has heavy periods.

Second- The kidney creates EPO. Since your pt has stage 3 CKD and you said normal iron studies and i assume either a microcytic or a normocytic anemia, it is almost for sure anemia 2/2 renal disease (chronic disease). This further goes with the fact that her K is rising and her GFR is falling, and she recently had a GU infection.

To be sure, i would resend some labs including CBC, BMP, LDH and retic count (uremia from renal failure causes hemolysis) and potentially consider a smear to r/o malignancy and confirm the diagnosis. Unless her MCV was low and is now normal, it is less likely B12 but if you want to, you could consider B12, folate and MMA. I wouldnt send the coombs just yet.

If you really want to confirm the iron pannel just send an iron and ferretin.

Don't take her off of the iron unless you have the lab work that goes with when they started the iron and can show she was not iron deficient. There was likely a reason they started it, and given the fact that she likely has chronic RBC destruction from the renal disease (not to mention poor production from the renal disease) she likely still needs the iron.