yogesh
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Pt with CRF (creat. 3.0)
HTN +
MCV 65
HCT 26
How do you treat it??
A) IM Fe
B) Transfusion
C) Erythropoietin
Edited by yogesh on 04/27/08 - 01:10 PM
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| liliaeliz
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B
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| chemamr
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what' s the Hb level?
what is HT? = hemoccult?
incomplete question, thus I'm unable to give an accurate answer, but it could be C + PO iron, couldn't be?
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| yogesh
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Sorry for unclear informations.
HT=Hypertension
HCt=26 No Hb level was given. And I wrote only the important information from which to decide.
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| yogesh
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Sorry for unclear informations.
HT=Hypertension
HCt=26 No Hb level was given. And I wrote only the important information from which to decide.
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| guangyu
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if pt have symptom, transfer
if no symptom, fe po and erythropoietic
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| Eagle_303
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Erythropoitin deficiency does not have microcytic anemia.
MCV = 65fL means microcytic anemia
In CRF it is normochromic normochromic anemia.
Because there is microcytosis the option is Fe therapy
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| yogesh
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I also thought the same rationale. But why would i give him IM from the beginning?? Can it be transfusion?
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| Eagle_303
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yogesh wrote:
I also thought the same rationale. But why would i give him IM from the beginning?? Can it be transfusion?
Transfusion ? of what ?
If you say blood transfusion.These are always in emergency blood loss.Usually it is not used to correct anemia unless there is some specific indication like aplastic crisis of SCA or heavy blood loss.
There is no sense in overloading the normovolumic patient
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| chemamr
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Hypertension is usually HTN (no HT) in american books.
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| chemamr
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I keep my answer.
no need for transfusion and no need for Intramuscular Fe.
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| yogesh
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chemamr wrote:
Hypertension is usually HTN (no HT) in american books.
you are right. I need practice for acronyms.
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| yogesh
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chemamr wrote:
I keep my answer.
no need for transfusion and no need for Intramuscular Fe.
Best choice here would be PO Fe + Epoietin.
As we are not given that, the question here is "would you give erythropoietin to an Fe deficient patient without replenishing iron stores?"
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| Markus2009
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I would picked erythropoyetin because I think the concept that they are asking is the need of erythropoyetin in chronic renal insufficiency. It is true that this patient needs iron replacemente as well for the demand of the bone marrow in producing more RBC but the main treatment of anemia due to chronic renal failure is erythropoyetin. We have to keep an eye on the blood pressure as well for the side effect of erythropoyetin.
Agree with you about treatment with Fe + erythro
Edited by Markus2009 on 04/22/08 - 08:10 PM
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| doc649
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if I have to choose one, I'd chose po iron
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| usmletopper2
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In chronic renal failure ,there is decresed erytropoietin.but when we supplement erythropoeitin alone ,there depletion of iron stores leading to fe def anaemia,thus im / Iv fe need to be supplemented in these pts.
i would pick Im fe.
explanation given in UW
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| Ivonne
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It is difficult to answer because it seems an incomplete question but I agree that the anemia due to CRF is normocytic, normochromic therefore in this patient it is important to rule out first Fe deficiency whichIt is hard to diagnose based only on the MCV....
I would't give erythropoyetin without replacing first Iron stores so my answer is IM Fe------>A
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| yogesh
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I googled it few days back and read some articles. They say that microcytic anemia in CRF can not be due to erythropoietin deficiency alone. The most common cause here is Fe-def. CRF + Dialysis cause increase Fe loss through GI (they proposed some mechanism for this but I've forgotten). In this situation, only E-poietin can not raise Hb. You have to replace the Fe stores with "IV Fe"!!! first. Oral Fe cannot sustain the pace at which the Hb is produced because of unpredictable absorption specially in renal failure.
None of them mentioned IM Fe. But from this, I would go for IM Fe..
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| Pioglitazone
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An interesting possibility could be 'anemia of chronic renal disease' in a person with thalassemia trait.
in which case, E poeitin will be the answer. HCT in CKD can be as low as 20. The MCV however is not low in isolated CKD.
That said, let's read this:
The mainstay of the treatment of anemic patients is the use of recombinant human erythropoietin (rHuEPO). The response to treatment is impressive and the need for transfusion is importantly decreased. Upon initiation of therapy a target hematocrit should be set as well as the iron stores should be completely evaluated (since low stores may blunt the proliferative response to erythropoietin). The beginning of therapy should be gradual to avoid excessively rapid increases in the red cell mass with its hyperviscosity consequences. A total weekly dose of 110 to120 U/kg divided into two or three subcutaneous injections is an adequate thaerapeuric regimen.
Read this part again:
Upon initiation of therapy a target hematocrit should be set as well as the iron stores should be completely evaluated (since low stores may blunt the proliferative response to erythropoietin).
Throughout the course of therapy, iron stores(serum iron, ferritin and TIBC) should be determined frequently, since the rapid proliferative response may not be accompanied be an adequate availability of iron. If the iron stores are proved insufficient during the course of therapy, replacement should be started without delay.
IM Fe + Epoeitin
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| yogesh
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Hey pioglit,, good job.
As you said, and we all know that anemia in crf is treated with e-poitin. and we need to check fe stores regularly and we replace stores at the very first indication of inadequate stores.
The question here is,,
What is more priority here WHEN Fe STORES ARE SEEMINGLY INADEQUATE SINCE THE BEGINNING? Is it Fe OR E-poietin? (We don't have the option of fe AND epoietiin).
One more reason why I'd choose Fe before e-poitin..
We have a microcytic anemia (most probably due to Fe Def.) in CRF.
So we have 2 possibilities for its cause.
1) Fe deficiency (higher Fe loss) + E-poietin def due to renal damage
2) Fe Deficiency ALONE!!! (THIS IS ALSO A POSSIBILITY. not ALL CRF pt have e-poitin deficiency)
I would not want to give e-poietin (a potentially harmful in terms of HTN and a very costly drug) to a pt with Fe Def. anemia. So I'd start with Fe (PO, IM or IV) alone first and see the response. Even if it doesn't cure the anemia it's surely gonna raise the stores so giving e-poietin will be effective afterwards if it turns out to be E-poietin deficiency as well.
[I thnk he best next steps here would be.. check Fe status with TIBC & Ferritin. Then start Fe IV/IM + E-poitin. what do you say?] but we are on a discussion for these three options only.
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| Justice
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Just a thought: one of side effects of erythropoietin Rx is HTN... I guess history of HTN in the past is given to say that e-poietin, useful otherwise, will be dangerous in this Pt...
With HCT 26 I would transfuse this Pt with a unit of erythromass... RE IM will take too long to reach reasonable compensation...
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| yogesh
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Justice wrote:
Just a thought: one of side effects of erythropoietin Rx is HTN... I guess history of HTN in the past is given to say that e-poietin, useful otherwise, will be dangerous in this Pt...
hi justice,
Won't many of patients with CRF have HTN?? When you give E-poietin to them, you manage by increasing the doses of HTN Rx not by avoiding Epoitin.
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| Justice
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yogesh wrote:
hi justice,
Won't many of patients with CRF have HTN?? When you give E-poietin to them, you manage by increasing the doses of HTN Rx not by avoiding Epoitin.
Desire to manage potential HTN exacerbation is not practical... Your ability to increase doses of drugs are limited to ZERO when there is no filtration and excretion of metabolites by dysfunctional kidneys... And, in fact, I am not against epoietin in midterm management of this patient... But immediate improvement could be achieved by packed erythrocyte transfusion...
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| Justice
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When it comes to prep for step 3, it feels better to solve qns, because they specifically as what they want to hear from you...
This particular qn is about understanding of pathogenesis of anemia in patients with CRF, that is lack of epoietin produced by kidneys...
To give a broad answer, I say C) Erythropoietin
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| yogesh
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Justice wrote:
When it comes to prep for step 3, it feels better to solve qns, because they specifically as what they want to hear from you...
This particular qn is about understanding of pathogenesis of anemia in patients with CRF, that is lack of epoietin produced by kidneys...
To give a broad answer, I say C) Erythropoietin
Just a healthy discussion Justice..
Can't it be asking about pathogenesis of Fe Def. in CRF when you'll give Fe rather than epoietin.
And I have seen much overlap between step1& step2 and same way step2&step3. So it really doesn't matter in which forum we are discussing the Qs.
Basically, none of us know what is the correct answer. I posted the question to know what you all think. i think that's enough. We had a wonderful range of thoughts here. Each of all 3 options were defended by someone with good reasoning.
I hope some people got benefit from the discussion (though we couldn't reach a common conclusion). But in USMLE it's the processing that matters as much as the content that we've stored.
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