Process of anemia in ESRD- why do they have it?

 

Patients with ESRD often have a normochromic normocytic anemia. One study found that 68% of those with CKD needing hemodialysis had a hematocrit under 30%. This is because the kidney makes 90% of EPO which stimulates RBC production (the liver makes a small amount). Thus, as the kidney function decreases, EPO production decreases as well, resulting in anemia. Furthermore, there is increased hemolysis and increased venipunctures amongst CKD patients.

 

Anemia is more common in CKD patients as their GFR is below  60 mL/min/1.73 m2. Other risk factors are being African-American, diabetic, and male. While women usually have a higher incidence of anemia in child-bearing years, males with CKD are more likely to be in the more advanced stages and thus have higher rates of anemia amongst CKD patients. 

 

This anemia is treated with erythropoiesis-stimulating agents (ESAs), which in the US are epoetin alfa and darbepoetin alfa. There has been much discussion on how to manage these patients, as ESAs have a black box warning for increased CVD events (strokes, MI, heart failure). Thus, the therapeutic goal is to not completely normalize hemoglobin but to just avoid the need for transfusions. Patients should not be treated for a goal above 11.5 hemoglobin. Pediatric patients should be treated for a goal of between 11 and 12. 

 

Checking Hb Timeline for CKD (2012 KDIGO):

• Non-anemic: at least yearly for CKD3; every 6 months for CKD4 and CKD5; at least every 3 months if on HD
• Anemia but not treated with ESA and not on HD: check every 3 mo
• Anemia, HD but not treated with ESA: monthly
• Being treated with ESA: monthly, at least initially

 

https://emedicine.medscape.com/article/1389854-overview

https://www-uptodate-com.york.ezproxy.cuny.edu/contents/treatment-of-anemia-in-hemodialysis-patients?search=anemia%20esrd&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

 

Ascites Pathophysiology, causes, diagnosis and treatment. 

Pathophysiology

The damage from viruses or alcohol causes hepatocellular damage. Over time, the healing process causes regenerative nodules with fibrotic tissue in between, causing cirrhosis of the liver. The fibrosis of the liver causes it to compress the sinusoidal space, causing increased pressure (portal HTN). This portal HTN causes the fluid to get pushed into tissues and the peritoneal cavity. Because the liver is at such a high pressure and cannot handle the fluid, it backs up into the spleen causing congestive splenomegaly. Furthermore, decreased liver function results in decreased albumin production and less oncotic pressure as a result. 

 

Causes

Cirrhosis is the most common cause of ascites, with 50% of patients getting ascites within 10 years of their diagnosis of cirrhosis. Other causes include heart failure, cancer, nephrotic syndrome, and malnutrition. The etiologies are as follows: cirrhosis and heart failure causing portal hypertension, nephrotic syndrome and malnutrition resulting in hypoalbuminemia, and cancer resulting in peritoneal disease. 

 

Dyspnea is common and the ascites can be accompanied with abdominal discomfort or painless. If there is spontaneous bacterial peritonitis, the patient may have fever, abdominal tenderness, and altered mental status. Ascites develops over days to months, usually taking a few weeks if cirrhosis and a few months if cancer.  

 

Diagnosis:

PE- Distended abdomen, especially specific if there is dullness in the flank and shifting dullness present. 

 

Labs- Done to evaluate the underlying cause. 

• Cirrhosis- Low albumin, platelets, RBC, WBC
• Spontaneous bacterial peritonitis- leukocytosis, metabolic acidosis, azotemia

Imaging

• Abdominal ultrasound is more commonly performed, as it is very cost-effective. 
• Imaging should also be done to look for underlying causes, like cirrhosis and cancer, via CT, MRI, or ultrasound again. A nodular liver is suggestive of cirrhosis. 
• Portal HTN will show dilation of the portal vein above 13 mm and dilation of the splenic and superior mesenteric veins over 11 mm. 

 

The International Ascites Club has made the following grading system:

• Grade 1 – Mild ascites detectable only by ultrasound examination
• Grade 2 – Moderate ascites manifested by moderate symmetrical distension of the abdomen
• Grade 3 – Large or gross ascites with marked abdominal distension

 

Furthermore, abdominal paracentesis is obviously an effective means of diagnosis, with the additional ability to help identify the underlying cause and confirm/ rule out spontaneous bacterial peritonitis, which is crucial in these patients, as mortality increases 3.3 % for every hour until the paracentesis is performed. An analysis of the fluid can also provide many clues.

• Color- cirrhosis (clear), turbid/ cloudy (infectious), bloody (cancer)
• Serum to ascites gradient- calculated by subtracting the ascitic albumin level from the serum albumin level; over 1.1 g/dl is 97% likely to be resulting from portal hypertension
• Cell count and differential: this is the best to confirm SBP; if the neutrophil count is over 250 then antibiotics should be started

 

Treatment

Alcohol cessation can greatly improve outcomes if the patient has cirrhosis, whether resulting from alcohol or not. Treating the underlying cause is also beneficial. Sodium should be restricted to 2000 mg/ day. 

 

A combo diuretic regimen is of spironolactone and furosemide is more effective than either separate, with a ratio of 100:40 mg/day, increased every 3 to 5 days.

 

Paracentesis is an effective option especially if there is an urgent need to decompress the abdomen. Furthermore, when removing 5 liters or less there is minimal concern for hemodynamic compromise and thus there is no need for albumin replacement. However, above 5 L, consider replacing albumin at 6-8 g per liter of fluid removed. 

 

https://www-uptodate-com.york.ezproxy.cuny.edu/contents/ascites-in-adults-with-cirrhosis-initial-therapy?search=ascites&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H1

https://www-uptodate-com.york.ezproxy.cuny.edu/contents/evaluation-of-adults-with-ascites?search=ascites&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H341237824

https://www.osmosis.org/learn/Cirrhosis