Background: Will Erythropoietin Use in this CKD patient help us?

67-year-old man with a history of CKD stage 3B, hypertension, and lower urinary tract symptoms is in the intensive care unit with septic shock related to pneumonia.

Prior to admission, the patient was on losartan for his hypertension.

The patient was appropriately resuscitated with fluids and antibiotics. Nephrology was consulted to assist with AKI and fluid management. The patient is stabilized.

The patient’s hemoglobin went from 10.2 down to 7.1 two days after resuscitation. He is currently stable.

mircera is a form of erythropoietin — Mircera is a long-acting form of erythropoietin, frequently used outpatient. In the hospital, shorter acting formulations are usually preferred.

Please answer the following questions:

What is the next step to approach this patient’s anemia?
* Continue current therapy.
* Perform a blood transfusion with a goal hemoglobin of 10.
* Perform a blood transfusion with a goal hemoglobin of 12.
* Start Mircera after making sure the patient is iron replete.
* Start erythropoietin after making sure the patient is iron replete.

Answer: continue current therapy.

For critically ill and ward patients who are euvolemic, not actively bleeding, and do not have acute ischemic heart disease, it is recommended to use a restrictive transfusion threshold of 7 g/dL (70 g/L).

A restrictive transfusion threshold of 7 g/dL (70 g/L) is not applicable for the following patient types: severe thrombocytopenia, chronic transfusion-dependent anemia, and acute coronary syndrome.

Patients with active ischemic heart disease do better with a more cautious transfusion trigger.
A
True
B
False

False. This is a scenario when transfusing above the 7 g/dL threshold may be appropriate.

Guidelines recommend a restrictive erythrocyte transfusion threshold for hospitalized adult patients who are hemodynamically stable.
A
True
B
False

True

Patients with severe thrombocytopenia are included in the group recommended for a more liberal transfusion strategy.
A
True
B
False

True. These patients with low platelets have a risk of bleeding and may need the additional blood to buffer a possible loss of blood.

Erythropoietin therapy is recommended for patients with chronic kidney disease not requiring dialysis who have a hemoglobin level greater than 10 g/dL.
A
True
B
False

False

Higher hemoglobin targets in patients receiving erythropoietin therapy are not associated with adverse events.
A
True
B
False

False

Discussion:

➡️Learn More⬅️

Anemia Management in Critically Ill Patients, Blood Transfusion Thresholds, and the Use of Erythropoietin

Blood Transfusion Thresholds

A randomized controlled study in euvolemic critically ill patients showed benefits of a cautious transfusion trigger (hemoglobin < 7 g/dL) over a liberal trigger (hemoglobin < 9 g/dL). The lower trigger group had improved 30-day mortality and fewer complications, like pulmonary edema or myocardial infarction. However, patients with active ischemic heart disease fared better with a more liberal transfusion strategy, transfusing to above 7 g/dL when indicated.

Guidelines recommend a restrictive transfusion threshold. A restrictive transfusion threshold means not transfusing the patient until the hemoglobin is below 7 g/dL for stable hospitalized adult patients. This strategy also applies to critically ill patients.

Exceptions to this rule include patients with acute coronary syndrome, severe thrombocytopenia, and chronic transfusion-dependent anemia.

Erythropoietin Therapy in Anemia of Chronic Kidney Disease

Erythropoietin is essential in treating anemia of chronic kidney disease (CKD), especially in end-stage kidney disease patients on dialysis who are iron replete. Guidelines suggest withholding erythropoietin-stimulating agents (esas) in non-dialysis CKD patients with hemoglobin > 10 g/dL to avoid adverse events like worsening hypertension and volume overload.

For this patient with mild, asymptomatic anemia likely because of sepsis and dilution from fluid resuscitation, erythropoietin therapy is not recommended because the dilutional anemia should improve with recovery from the current illness.

Inspiration: Hospital discharge hemoglobin values and post-hospitalization clinical outcomes in transfused patients undergoing non-cardiac surgery, National Library of Medicine

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