Low H&H, with normal platelets, no FVE

[shanrah]

Hi,

On our careplans, we attempt to figure out why there are any abnormalities, and I stumped on this one...any input is appreciated:

Pt is 89 y/o Asian female, 85 pounds, no hx of anemia, only hx of HTN controlled with Toprol. She has hydronephrosis, and is schduled for surgery to remove pelvic tumors that have caused partial urinary obsturction on rt. side (however, the pt. maintained over 30ml/hl of output, due to having a stent placed in the rt. ureter) She presented with hematuria, in her UA it just stated "too numerous" under RBC's present

Pertinent labs:(blood)

WBC:15.9, neutropjils 90 %, (although only trace bacteria was noted in her UA, white cells in UA was 5-10) She was receiving Levaquin and Vanc IV

RBC: 3.57

H&H: 10.8, 32.2

Platelets: 283

BUN: 16

Creatine:0.8

Albumin: 2.3

ALT/SGPT: 8

Alk. phosphate:70

Total Bili: 1.5

INR: 1.1

protein 62 g

She was malnourished, and on TPN regular lipids at 39 ml/hr with free water, via triple lumen subclavian.

She did not have FVE, so I am wondering why her H&H, and RBC's were low, and not her platelets? Would it have something to do with the production of erythpoiten impaired with the kidney? This one has stumped me, she did not have any other disease processes going, no chronice renal failure, dialysis, etc. She just had blood in her urine, but would it cause her counts in red to be that low with normal platelets?

Anyone feel like brainstorming?

:)

Lauren

[babs_rn]

I know it's a little late, been awhile since your post, but in the interest of discussion ... how long before this cbc was the stent placed? Acute Renal Failure might have something to do with it, in conjunction with the blood loss from her kidneys (which I hope has been investigated), plus any surgical procedures and/or inflammatory processes going on with her that would make her system resistant to even naturally produced erythropoeitin. All of this will cause a drop in hemoglobin. Typically we also investigate any possible GI bleeds, simple hemoccults, to rule out any further blood loss.

Since it has been awhile, what was found and how is she doing now? Just out of curiosity....

[Serenyd]

I had a pt like this the other day - hx of chronic anemia, not really sure why, they thought she might have low iron, but her iron levels were above normal. Last H+H 7,22. Hx of cervical CA. They found hydronephrosis from tumor obstruction and had to put a stent in both ureters. She did get a shot of erythropoetin right before sx, I guess it was kidney related. Never could get a stool sample for occult blood - she wasn't eating very much and the one time she did go she forgot to save it.

[LLLovely, BSN, RN]

Post-renal acute renal failure will cause a drop in erythropoeitin and thus a drop in H&H. Platelets remain normal for a while, but BUN and creatinine rise. There may be oliguria/anuria and hematuria. You would expect K+ to be up also.

Although, it could be confusing if it is a pre- or intra-renal ARF. Some pts. are given diuretics (Lasix) to assist until underlying factors can be alleviated. If the diuretic is successful, hypokalemia may manifest and the pt. will require supplementation.

It is crucial to monitor daily labs to stay on top of elctrolyte and acid-base balance. Remember that an IV gets fluid into the vascular system, but it doesn't keep it there. FVE is common, but FVD is also possible. I had a pt. with that this week and her BP dropped very low because her IV fluids had been d/c'd. A 250 cc bolus brought her back up and a new flow rate was ordered to maintain volume.

I know this thread is old, but the topic comes up regularly on the Med-Surg floor.