What's Going on with Patients Hgb?

[NerdyMedSurgNurse]

I have been taking care of a patient on the MedSurg floor of the hospital for a couple of days now. She's in her mid thirties, no children, is married, and is a former IV drug user. She stated she has a hx of cardiomyopathy, that her family doctor attributes to the drug use. Her admitting Dx is: anemia and acute kidney injury. When I went into do her first assessment after admission, the first thing I noticed was how remarkably swollen her lower extremities were. I've seen edema before, but NOTHING like this. She's +4 from the top of her thighs all the way to her feet. The doctor has her on NS 75/hr along with a crap load of Lasix in variable amounts (differs each day in new orders). She's on tele, and has been running 80-90 at normal sinus. Her first set of labs were: Hgb: 7.4, Hct: 31%, GFR: 17, K+: 3.9, Na+: 133, Creatnine: 3.3, and BUN: 44. (I'm sorry I'm not able to remember much else of the labs, but these were the ones the docs were keeping close eyes on.) She was given 1 unit of blood on day shift, and had labs drawn roughly 6 hours afterward. Her Hgb was up to 8.2. Overnight, her hands started to swell (i'm telling you, they looked like Mickey Mouse gloves once I came on shift). More labs were drawn that morning and her Hgb was back down to a high 6. She received 2 more units of blood with 80mg Lasix before the first transfusion, 40mg in between the first and second, and another 40mg following the second. Doc ordered hemoccult and some urine tests. No blood in either sample. She doesn't have any hematemesis. Abdominal CT and Ultrasounds were done to scan for internal bleeds. Everything was clear. Doc discontinued her IV fluids. My question here is: is the AKI attributing to her Anemia, or is it the other way around? What in the world could be causing this lady's Hgb to continue to drop? I'm sorry I don't have much more information, this is what I could remember of her chart.

[LovingLife123]

I had a person one time who they thought his cells were eating each other. Did they do a test for fibrin to make sure they weren't going into DIC?

I had a guy with crazy low hgb and was in kidney failure and not bleeding from anywhere. The hematologist had mentioned maybe his cells were eating each other. I forget what she called it.

I never did find out what made his hgb so low.

[NerdyMedSurgNurse]

I'll have to look when I get back to work on Friday. I assume she'll still be there. I don't remember seeing any fibrin testing, though. I don't think I was really looking for it, so it definitely could be there, and I just overlooked it. It's hard for me to question the docs due to being on night shift. It's probably a good thing. My curious mind would drive them nuts haha

[calivianya, BSN, RN]

Your kidneys make your erythropoietin, so when they're not working, you're going to be anemic. Just an it is what it is sort of thing.

Also, if she's got that much extra fluid on board, probably some of the anemia is dilutional.

A third factor is she could indeed be chewing up the new RBCs she's getting. It's worth considering that she might have used some dirty needles when she was abusing IV drugs. Dirty needles = potential exposure to other people's RBCs, plasma, proteins, etc. and therefore development of new antibodies. The more antibodies she has, the more difficult it's going to be to get blood that's perfectly compatible for her, and the more likely she is to chew up transfused blood.

We're pretty good at closely matching blood now, but I want to say I've had at least three people in the past month that blood bank made me come and get the blood and made the physician sign an emergency release form because the people had so many antibodies that we were transfusing the "least incompatible" blood, not actually compatible blood. I learned last time I went down that my hospital saves out one "perfect" irradiated, CMV negative, purest of pure units of blood for the preemies in the NICU. I ended up grabbing that unit for one of my adult patients one day because he had so many antibodies and his Hgb was so low.

[smf0903]

We had a guy one time who had cold agglutinin anemia and presented very similarly. Look it up, it's a rare form of hemolytic anemia and quite interesting!

[AJJKRN]

This link may give you more insight:

The Effects of Heart Failure on Renal Function

[blondy2061h, MSN, RN]

I had a patient with aHUS once. The presentation sounds remarkably similar. They need to check a haptoglobin to look for hemolysis. It definitely sounds like a hemolytic component. I hope she had a hematology consult.

Kidney injury does cause anemia but I've never heard of it being that severe and refractory with a relatively mild kidney injury.

[YoutubeTheNP]

More information certainly would be helpful. I always laugh when I hear a patient is getting IV fluids and IV lasix. It's such an oxymoron to me.

Anyway, if she has a hx of cardiomyopathy I would love to know what her BNP is. All that swelling you mentioned was probably acute heart failure on top of acute renal failure. Her anemia could be cause by a bunch of stuff: CKD being one of them. You also said she was in her 30s, still menstruating. ID anemia the most common cause of anemia in women. If her MVC (mean corpuscular volume) was less than 80% then you can pretty much put your money on iron deficiency. How did her chest x-ray look, and did they do an echo? What was her EF?

[canoehead, BSN, RN]

Is the reticulocyte count normal? Or iron studies? She's in renal failure, and perhaps her kidneys aren't releasing the erythropoietin needed. And if she's puffed up like a balloon, why are they giving her fluids? Is she eating, and getting vitamins necessary for blood formation?

My very uneducated opinion would be give her albumin, suck the fluid out of the tissues, then Lasix to get it out of the body. But I bet someone has already done a study, and found it didn't work.