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Iron metabolism And Anemia in chronic kidney disease Chittima Sirijerachai

Anemia in chronic kidney disease 16/Jittama... · • Heme iron compound : Hb, myoglobin ... No other causes of anemia Iron deficiency anemia Nutritional deficiency anemia GFR

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Text of Anemia in chronic kidney disease 16/Jittama... · • Heme iron compound : Hb, myoglobin ... No...

  • Iron metabolism

    And

    Anemia in chronic kidney disease

    Chittima Sirijerachai

  • Iron distributionIron distribution

    – Intracellular ferrous iron• Heme iron compound : Hb, myoglobin

    • Iron containing enzyme

    – Intracellular ferric iron• RE cell, heart, epithelial cell of small intestine

    - Ferric-transferrin

    Intracellular iron

    Extracellular iron

  • Dietary iron1-2 mg/day

    Liver1000 mg

    Spleen600 mg

    Plasma transferrin3 mg

    Slough mucosal cell1-2 mg/day

    Myoglobin300 mg

    utilization

    Bone marrow300 mg

    Erythrocyte1800 mg

    utilization

  • Iron absorptionIron absorption

    Fe+++

    Fe++

    Fe++

    Fe++ ferritin

    Fe+++ - transferrin

    Promote absorption

    -Fructose

    -Vitamin C

    -Heme iron

    -Amino acidInhibit absorption

    -Phosphate

    -Phytate

    -Tannin

    -Soil clay

    HCl

  • Iron absorptionIron absorption

  • Regulation of iron absorptionRegulation of iron absorption

    Dietary iron – mucosal block

    Iron stores – store regulator

    Erythropoitic regulator

  • Heme

    Iron utilizationIron utilization

  • Dietary iron1-2 mg/day

    Liver1000 mg

    Spleen600 mg

    Plasma transferrin3 mg

    Slough mucosal cell1-2 mg/day

    Myoglobin300 mg

    utilization

    Bone marrow300 mg

    Erythrocyte1800 mg

    utilizationIron deficiency anemiaIron deficiency anemia

  • PlasmaFe-Tf

    Liver spleen

    Bone marrow

    rbc

    inflammation

    hepcidin

    hepcidin

    Anemia of chronic diseaseAnemia of chronic disease

  • Iron studyIron study

    Serum iron

    Total iron binding capacity (TIBC)

    Transferrin saturation (Tf sat)

    Ferritin

  • Iron depletionIron depletion

    erythrocyte

    Iron stores

    normal functional absolute

    Serum ferritin(ng/ml)

    > 100 > 100 < 100

    Tf sat%

    > 20 < 20 < 20

  • - iron- protein- etc

    erythropoietin

    Decreased production

    Blood lossIncreased destruction

  • Causes of anemia in ESRDCauses of anemia in ESRD

    Decrease erythropoietinIron deficiencyNutritional deficiencyDecrease red cell survivalBone marrow suppression by uremiaOsteitis fibrosa cysticaInflammationAluminum toxicity

  • Work-up for a diagnosis of anemia in CKD

    Work-up for a diagnosis of anemia in CKD

    Adult male < 13.5 g/dl

    Adult female

  • Diagnosis of renal anemiaDiagnosis of renal anemia

    Significant impairment of renal function

    No other causes of anemia

    Iron deficiency anemia

    Nutritional deficiency anemia

    GFR < 30 cc/min, Cr > 2 mg/dl

  • Diagnosis of renal anemiaDiagnosis of renal anemia

    History taking

    Physical examination

    - Dietary intake

    - Chronic blood loss

  • InvestigationInvestigation

    CBC

    Iron study, ferritin

    Red cell indices

  • CBC and RBC indicesCBC and RBC indices

    80-96 fl.27-33 pg.33-36 g/dl

    12.0-13.6%

  • Iron study, ferritinIron study, ferritin

    TSAT < 20 %

    Ferritin < 100 ng/ml

    Iron deficiency anemia

  • Treatment of renal anemia

  • Benefit of anemia control in ESRDBenefit of anemia control in ESRD

    Increased survival

    Decreased cardiac complication

    Improved quality of life

    Increased exercise capacity

    Decreased hospitalization

  • Target for anemia treatmentTarget for anemia treatment

    Hb > 11 g/dl Hct > 33 %

    Within 4 months

    Ferritin 200-500 ng/ml

    TSAT 30-40 %

  • Treatment of renal anemiaTreatment of renal anemia

    Eryhtropoietin

    Adequate dialysis Nutritional support

    Iron therapy

  • Iron therapyIron therapy

    Improved response to EPO

    Reduced dose of EPO

  • Iron therapyIron therapy

    VSVS

    Oral iron IV iron

    Iron sucrose(venofer)

  • Iron therapyIron therapy

    - Ferrous sulfate 1 x 3

    - Iron sucrose 25-150 mg/wk

    Monitor:- serum ferritin, TSAT q 1-3 months

  • Iron therapy in CKDIron therapy in CKDSerum ferritin

    Transferrin saturation

    < 100 ng/ml - iron deficiency

    > 800 ng/ml - stop iron Rx

    < 20 % - iron deficiency

    > 50 % - stop iron Rx

  • Side effects of iron therapySide effects of iron therapy

    Oral iron - GI irritation- Diarrhea- Constipation

    IV iron - anaphylactoid- hypotension- muscle cramp

  • Erythropoietin Erythropoietin

    Erythropoietin α

    Erythropoietin β Recormon

    EprexEporonEpokrine

  • Erythropoietin Erythropoietin

    80-120 U/kg/wk SC

    120-180 U/kg/wk IV

    Hb 1-2 g/dl/month

  • Erythropoietin Erythropoietin

    Side effects

    - hypertension

    - PRCA

    - headache

    - Thrombosis

  • Inadequate erythropoietin responseInadequate erythropoietin response

    Patient fail to attain the target Hb while

    receiving:-

    EPO 300 U/kg/wk SC

    EPO 450 U/kg/wk IV4-6 months

  • Inadequate erythropoietin responseInadequate erythropoietin response

    Iron deficiency anemia

    Chronic blood loss

    Chronic inflammation

    Inadequate dialysis

    hyperparathyroidism

  • Iron distributionCBC and RBC indices