Management of Anemia by Robert Provenzano Edgar V. Lerma & Lynda Szczech

Author:Robert Provenzano, Edgar V. Lerma & Lynda Szczech
Language: eng
Format: epub
Publisher: Springer New York, New York, NY

Treatment

The advent of human recombinant erythropoietin, in 1989, revolutionized the management of the anemia in patients with chronic kidney disease. Before then, management of anemia in CKD patients essentially consisted of blood transfusions and androgen therapy. Transfusions improved hemoglobin, leading to improved symptoms and quality of life. Testosterone enanthate was also regularly used in conjunction with blood transfusions in ESRD patients. Its mechanism of action was thought to be the induction of endogenous EPO production, sensitization of progenitor to the effects of EPO, and increased RBC survival [17–20]. Its use was limited due to its side-effect profile, including acne, virilization, peliosis hepatis (the formation of blood-filled cavities in the liver), priapism, sexual dysfunction [21], liver function abnormalities, and the risk of hepatocellular carcinoma .

Complications of blood transfusions are manifold and include, but are not limited to, transmission of infection, both bacterial and viral, immune and allergic transfusion reactions, including transfusion-related acute lung injury and anaphylaxis, iron overload, volume overload, and hyperkalemia [22–27]. The last two, as expected, are more frequently encountered in the CKD and ESRD population. This was highlighted in a recent prospective study following 7829 patients with CKD 4 and 5, non-HD patients hospitalized with a diagnosis of hyperkalemia or heart failure. Transfusions increased the risk of hyperkalemia sixfold and heart failure by nearly fourfold [28]. Blood transfusions also have a negative impact on sensitization to new antigens, ultimately resulting in a prolonged wait on the transplant list for a renal allograft—a life-prolonging therapy! [29] Based on data from the 2010 United States Renal Data System , transfused patients were three times more likely to be highly sensitized than those who never received a transfusion. These data translate into a dramatically longer wait time, with those unexposed having about a 2.5-year wait, while those highly sensitized had a wait that was greater than 5 years [30].

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