MANAGEMENT OF ANEMIA IN RENAL PATIENTS
Introduction
Anemia is a serious medical condition which manifests in renal patients. Management of anemia in these patients is a collaborative effort which involves the general practitioner, the nephrologists, the specialist and the nurse. This paper will look into the roles these healthcare professionals play in the management of anemia.
Body
Renal failure can either be acute or chronic. Acute renal failure is the clinical condition associated with rapid, steadily increasing azotemia, with or without oliguria. The causes of renal failure can be grouped into three diagnostic categories: prerenal (inadequate renal perfusion), postrenal (obstruction), and renal. Prerenal and postrenal are potentially reversible if diagnosed and treated early, and some of the causes of primary renal injury which result in acute tubulointerstitial nephropathy are also treatable, such as bacterial infections, drug reactions, and metabolic disorders.
Initial evaluation of acute renal failure should seek reversible or specifically treatable causes of acute renal failure. Bladder neck obstruction is probably the most common cause of sudden, and often total, cessation of urinary output, especially in older men. A preceding history of difficulty in voiding is frequently given.
Chronic renal failure on the other hand is the clinical condition resulting from a multitude of pathologic processes which lead to derangement and insufficiency of renal excretory and regulatory functions (uremia). Chronic renal failure may result from any cause of renal dysfunction of sufficient magnitude.
When disease causes kidney failure or otherwise compromises the ability of the kidneys to remove toxic materials from the blood and maintain fluid, electrolyte, and acid-base balance, therapeutic dialysis by diffusion across a semipermeable membrane may be used. The patient’s own peritoneum or a machine using a synthetic semipermeable membrane such as cellophane may be used – peritoneal dialysis and hemodialysis, respectively.
Anemia is a frequent problem in patients with renal failure especially those in end stage and in chronic kidney disease (CKD) who are not yet receiving dialysis and can lead to major health complications if left untreated. The successful management of these patients entails repletion of iron stores, often through use of intravenous iron, particularly in patients receiving erythropoietin therapy. To encourage patient compliance with anemia management protocols, the nephrology nurse can play a key role in patient education in reducing barriers to proper management and in raising the awareness of the benefits of treating this condition (, 2001).
Nurses play a key role in helping to maintain Hb levels in the range recommended to mitigate anemia-related risk factors in both predialysis patients and those with end stage renal disease (ESRD). This is actually a situation which calls for a team approach comprising of the nephrologist, general practitioner, specialist and the nurse.
Additional progress in anemia management can be obtained by understanding, the importance of early diagnosis and treatment of iron deficiency. Several factors contribute to iron deficiency in renal failure patients.
First, observations with patients in the predialysis period, on hemodialysis, and on peritoneal dialysis suggest that intestinal iron absorption is reduced during ESRD. Poor absorption of iron can lead to the depletion of both circulating iron and iron stores, which is referred to as absolute iron deficiency. It has been suggested that low iron absorption in these patients may be explained by the intestinal mucosal changes that develop with uremia, including changes in activity of certain digestive enzymes–decreased activity of dipeptidases and increased activity of disaccharidases. Intestinal inflammation with associated histologic alterations may also be related to low iron absorption. Erosions and ulcers are additional gastrointestinal complications that often develop during ESRD. These are associated with gastrointestinal bleeding, which may also contribute to the development of iron deficiency. In hemodialysis patients, significant blood loss may also be caused by blood remaining in the dialyzers and dialysis lines postdialysis (, 2002).
All patients returning to the dialysis facility following hospitalization should be immediately assessed to determine their clinical status. This process should include both a complete review of hematologic parameters and an individualized assessment for the presence of comorbid conditions that could affect hemoglobin (Hb) levels either acutely or chronically (, 2004).
Anemia may be aggravated during hospitalization, and patients returning to the dialysis facility may present with Hb levels that are significantly lower than baseline. Clinical data indicate that anemia can persist after hospitalization, with some patients requiring up to 6 months to regain preadmission Hb levels. To optimize anemia-related outcomes, a special approach to minimize post-hospitalization anemia may be warranted.
Nursing interventions to proactively manage comorbid conditions, modify the anemia management prescription before hospitalization, and/or initiate a Rapid Ramping approach afterward can often minimize the severity of any decrease in Hb while shortening the time required to reaehieve targeted Hb levels (2004).
Proactive nursing interventions, including appropriate patient assessment, timely initiation of therapy, and individualized dose calculations, can help ensure that patients attain and maintain targeted Hb levels.
The anemia manager should monitor the trends in Hb levels and note the increase after weeks of therapy; iron parameters should remain within the targeted range. Assessment should be negative for other conditions that may contribute to a low Hb, and if the Hb levels rose, the Epoetin alia dose should be gradually decreased to the prehospitalization level of 80 Units/kg TIW. The Hb should be restabilized weeks after discharge (, 2004).
The iron status of patients with renal failures should be evaluated on a regular basis during both the predialysis and dialysis periods, since these patients are at risk for developing iron deficiency (, 2002).
The role of the nephrology nurse in the anemia management of ESRD patients has been reviewed previously. Nephrology nurses often play a key role in managing patients with CKD. Because of recognition of the importance of active management of CKD patients at earlier stages in the disease practice, more CKD patients are likely to be referred to nephrologists before they need dialysis (, 2001).
The advanced practice nurse, who is functioning as a physician extender, is more likely to work with patients in the predialysis setting than the nephrology nurse in standard practice who is usually involved with dialysis management. The advanced practice nurse may fulfill essential roles in identifying CKD patients at risk for developing anemia and managing the iron and EPO requirements of these patients (e.g., laboratory assessments of iron and hematology indices, prescriptions of therapies, etc.) (, 2001).
However, as more patients are being cared for by nephrologists at the predialysis phase, the nephrology nurse in the standard setting is likely to have increased contact with CKD patients. Nephrology nurses who do not oversee the direct medical management of CKD patients may still play vital roles in identifying anemic patients, promoting compliance, educating patients and health care personnel, and administering therapies. These functions are essential because several barriers exist to optimal anemia management in the CKD patient. For instance, patients and care providers may not understand the importance of anemia management and may question whether it is worth bringing CKD patients into the office weekly for injections.
Nephrology nurses can communicate the importance of anemia management over the long term and assure patients about the safety and efficacy of the available therapies. Reimbursement for EPO may involve a great deal of red tape, even though it is an important therapy. The health care team must be unified in its commitment to overcoming the barriers to these interventions (, 2001).
Early identification and aggressive treatment of anemia in CKD patients may improve patient outcomes such as cardiovascular function, quality of life, and morbidity/mortality. There is a need for greater awareness of the importance of early intervention. Nephrology nurses have assumed increased clinical responsibilities within today’s practice setting, and their role in managing CKD patients may increase in the future. Nephrology nurses can have a major impact on the clinical outcomes of CKD patients, primarily through patient education and improved patient compliance (, 2001).
(, 2002).
Documentation of anemia-related assessments, interventions, and outcomes is an integral component of proper anemia management for patients with ESRD. In addition to promoting vital communication among medical professionals, documentation helps fulfill regulatory, legal, and payer reimbursement requirements, thereby ensuring that nursing contributions to patient well-being are recognized and that access to care is preserved (2003).
It is important for nephrology nurses to understand the relationship that exists between renal disease, cardiac disease, and anemia. Even mild cases of chronic kidney disease (CKD) have been associated with an increase in adverse cardiovascular outcomes. And anemia, which can result from both CKD and congestive heart failure, has been shown to exacerbate the adverse consequences of these conditions. An early, aggressive correction of anemia in patients with CKD can be implemented to break this cycle and stop disease progression.
Studies have shown that anemia correction improves both cardiac and renal function and can result in increased hemoglobin levels, decreased number of hospital days, and improved quality of life. An effective strategy for managing anemia in patients with renal disease and comorbid cardiovascular disease includes the administration of both recombinant human erythropoietin and intravenous iron. In addition, the nephrology nurse plays an integral role in managing anemia and improving outcomes in these patients. Therefore, the nephrology nurse should have an increased awareness of the link between anemia and renal/cardiac disease as well as available treatment options (, 2005).
Recommendation and Conclusion
Anemia has long been recognized as a serious health problem in patients who have renal failures, especially those requiring dialysis. Successful treatment of anemia (i.e., increasing the hematocrit [hct] towards normal) in such patients is associated with reduced morbidity/mortality and significant improvements in cardiovascular and brain function as well as quality of life.
Although recent data indicate that the current anemia management protocols are resulting in good patient outcome, health care providers can still improve patient health by more aggressively addressing the problem of iron deficiency.
A good starting point would be to establish a simple iron deficiency management protocol that involves early detection and treatment during both the predialysis and dialysis periods. Clinicians can also improve the outcome of iron deficiency by optimizing iron therapy. The administration of safe and effective IV iron supplements, close monitoring of iron and hematologic parameters, and maintenance IV iron therapy will help clinicians achieve good patient outcome. Taken together, improvements in anemia and iron deficiency management will ultimately improve patient health and quality of life and may also reduce financial burden.
REFERENCES
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