Anemia Stage 5

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    Managing AnemiaWhen You Are on Dialysis

    Stage 5

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    NATIONAL KIDNEY FOUNDATION2

    What is anemia?

    Anemia happens when your red blood cellsare in short supply. Red blood cells carry oxy-gen from your lungs to all parts of your body,giving you the energy you need for yourdaily activities.

    Anemia can cause you to:

    Look pale

    Feel tired

    Have little energy for your daily activities

    Have a poor appetite

    Have trouble sleeping

    Have trouble thinking clearlyFeel dizzy or have headaches

    Have a rapid heartbeat

    Feel short of breath

    Feel depressed or down in the dumps

    What are some causes of anemia?

    Anemia can be caused by:

    Diseases like kidney disease, liverdisease, HIV/AIDS, systemic lupuserythematosus or cancer

    Diseases that harm or destroy your

    blood cells, such as sickle cell disease Blood loss from accidents, surgery,

    stomach ulcers, kidney or bladdertumors, cancer or polyps in the intes-tines or other causes

    An infection or inflammation inyour body

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    Too little iron, vitamin B12 or folic acid in

    your bodyIron is a mineral that you get from eat-ing foods like liver and leafy, greenvegetables. Both vitamin B12 and folicacid are important vitamins that you get

    from eating foods like eggs, fish andliver. Your body needs these importantminerals and vitamins to help make redblood cells.

    A poor diet

    You can become anemic if you do noteat healthy foods with enough vitaminB12, folic acid and iron. Your bodyneeds these important vitamins and min-erals to help make red blood cells.

    Before starting anemia treatment, your doc-tor will order tests to find the exact cause of

    your anemia.

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    Why do people on dialysisget anemia?

    Your kidneys make an important hormonecalled erythropoietin (EPO). Hormones aresecretions that your body makes to help

    your body work and keep you healthy.

    EPO tells your body to make red bloodcells. When you have kidney disease, yourkidneys cannot make enough EPO. Thiscauses your red blood cell count to dropand anemia to develop.

    Are all people on dialysis at riskfor anemia?

    Most people with kidney disease will develop

    anemia. Anemia can happen early in thecourse of kidney disease and grow worseas kidneys lose their ability to work well andmake EPO. Anemia is especially commonif you:

    Have diabetes

    Are African American

    Have moderate or severe loss of kidneyfunction (stage 3 or 4)

    Have kidney failure (stage 5)

    Are female

    If you are African American or havediabetes and chronic kidney disease,

    you are more likely to have anemiaand get it at an earlier stage of

    kidney disease.

    FACT

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    How do I know if I have anemia?

    Not everyone with anemia has symptoms.If you have kidney disease, you should

    have a blood test to measure your hemo-globin level at least once per year to checkfor anemia. Hemoglobin is the part of redblood cells that carries oxygen throughout

    your body. Your doctor can tell if you haveanemia by measuring your hemoglobin.If your hemoglobin level is lower than thenormal range (which is 12.0 for womenand 13.5 for men), it is likely you have

    anemia. In that case your doctor will checkto find the exact cause of your anemia anddevelop a treatment plan that is rightfor you.

    Speak to your doctor if you think youhave anemia. Make a list of questions.

    Write down your symptoms, allergies,medications, previous medical proce-dures and other health problems.Show the list of symptoms to your doc-tor. Discuss how you are feeling and

    ask questions.

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    How is anemia treated?

    If your anemia is due to kidney failure, you willbe treated with:

    Drugs called erythropoiesis-stimulatingagents (ESAs). ESAs act like the naturalhormone EPO, which helps your body

    to make red blood cells. Extra iron. Your body also needs iron

    to make red blood cellsespeciallyif you are receiving ESAs. Withoutenough iron, your ESA treatment will

    not work.

    What is the goal of anemiatreatment?

    The goal of anemia treatment is to increaseyour hemoglobin level to at least 11, which

    is considered to be the lowest level ofhemoglobin you need to feel well. As youget closer to or pass this level, you shouldnotice that you have more energy and feel

    less tired.

    Not having enough EPO (a hor-mone made by your kidneys) is themost common cause of anemia inpatients with kidney disease. EPOtells your body to make red blood

    cells. Treatment with an ESA can helpwhen your kidneys no longer makeenough EPO.

    FACT

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    How is ESA given?

    ESAs can be given to you in the followingways:

    As an injection under the skin. This iscalled a subcutaneous injection (SC).

    Injected through the blood tubes during

    dialysis. This is called an intravenousinjection (IV).

    You and your doctor will decide whichmethod is best for you.

    How much ESA will I need?

    Your doctor will prescribe enough ESAto increase your hemoglobin gradually tothe recommended level. How much ESA

    you need and how often you receive itdepends on:

    Your current hemoglobin level

    How well you respond to treatmentwith ESA

    The type of ESA you receive

    Two different types of ESAs are avail-ableshort-acting ESAs and long-last-ing ESAs.

    Short-acting ESAs are more effectivewhen given subcutaneously (as aninjection under the skin) rather than

    by IV (through the blood tubes duringdialysis). Examples of short-acting ESAsare epoetin alfa and epoetin beta.

    Long-lasting ESAs are equally effec-tive regardless of how they are given.

    Darbepoetin is an example of a long-lasting ESA.

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    How you receive your ESAas aninjection under the skin (SC) or through

    the blood tubes during dialysis (IV).

    How will my doctor know if I amresponding to ESA?

    Your doctor will check your hemoglobin level

    at least monthly. This tells your doctor how wellyou are doing. Your dose of ESA may needto be changed, depending on how well yourespond to your treatment.

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    Its important that you speak to your doc-

    tor if you are ever discharged from ahospital. Your doctor may want to modify

    your anemia treatment plan so that yourtarget hemoglobin level is maintained.

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    Will I need extra iron?

    Your body needs iron to make red bloodcells. Once you start taking an ESA yourbody will make more red blood cells, and

    your bodys iron supply will be used up faster.In addition, when you are on hemodialysis,

    some blood is lost in the dialyzer (artificialkidney), which also reduces the amount ofiron in your body. Therefore, you will probablyneed to take extra iron along with your ESA.Without enough iron, your ESA treatment willnot be effective.

    How much iron will I need?

    The goal of taking extra iron is to makesure you have enough to reach a hemoglo-

    bin of at least 11. Your doctor will decidehow much iron you get and how often youget it based on:

    Your hemoglobin level

    Your ESA dose Results of your iron tests

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    Iron is important in treating anemia.Without enough iron, ESA is wastedand you will not reach your targethemoglobin.

    FACT

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    How is my iron level tested?

    Two important tests can tell if you haveenough iron. They are called transferrinsaturation (TSAT)and ferritin. To make sure

    you have enough iron to reach the recom-mended hemoglobin:

    Your TSAT should be at least 20%

    Your ferritin should be:

    Greater than 200 ng/mL (when youare on hemodialysis)

    Greater than 100 ng/mL (when youare on peritoneal dialysis)

    How often will my iron levelbe tested?

    If you are being treated for anemia with anESA, your iron should be tested every monthuntil your anemia is under control. If you donot have anemia or if your anemia is under

    control, your iron level should be checkedevery three months.

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    Ask your doctor or your dialysis careteam for the results of your hemoglo-bin, iron and other important tests.Keep a record of these important labvalues. It can help you stay on target.The Dialysis Lab Log can help youdo this. To obtain a copy, ask yourdialysis care team or call the National

    Kidney Foundation at 800.622.9010.

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    How will iron be given to me?Iron is most effective when given by IV. IViron can be injected into the blood tubesduring hemodialysis. For patients receiv-

    ing peritoneal dialysis, iron can be giveneither by IV or as a pill by mouth.

    Can diet help my anemia?

    Eating foods that are high in iron, vitamin

    B12 and folic acid may be helpful for somepatients with anemia. Your dietitian canhelp you plan meals to include foods thatare good sources of these vitamins and

    minerals. Check with your doctor beforemaking any changes in your diet.

    How long will I needanemia treatment?

    You will probably need treatment forlifeeven if you have a successful kidneytransplant. Unfortunately, even a new kid-ney may not be able to make all the EPO

    you need to make enough red blood cells.One reason this happens is because the

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    immunosuppressive drugs needed after get-ting a new kidney can affect EPO produc-

    tion. So medication for anemia may still beneeded even after a successful transplant.

    What if my anemia isnt treated?

    If untreated, anemia can cause serious prob-lems. Anemia can make your other healthproblems worse. A low supply of red bloodcells in your body (anemia) can make yourheart work harder. This can lead to a type

    of heart disease called left ventricular hyper-trophy (LVH). Unfortunately, many peoplewith kidney disease develop LVH longbefore they reach kidney failure, and some

    will even die from it. Early treatment ofanemia may help prevent this problem andother serious complications from happening.

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    FACT

    Treating your anemia is importantbecause:

    Your chance of having serious, life-threatening heart problems is lower.

    You will have more energy to doyour daily tasks.

    Your quality of life gets better.Your ability to exercise improves.

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    Where can I get more information?

    You can speak to your doctor or othermembers of the health care team, or youcan call the National Kidney Foundationfor information. To learn more about kidneydisease, you may also want to read these

    free publications from the National KidneyFoundation:

    About Chronic Kidney Disease: AGuide for Patients and Their Families(11-50-0160)

    Diabetes and Chronic Kidney Disease(11-10-0209)

    GFR (Glomerular Filtration Rate):A Key to Understanding How Well

    Your Kidneys Are Working (11-10-1813)What Everyone Should Know About

    Kidneys and Kidney Disease(11-10-0101)

    You Can Save Your Own Life:Preventing Early Death From KidneyDisease(11-10-0240)

    Your Kidneys: Master Chemists of the

    Body(11-10-0103)

    To obtain a free copy of these book-lets or information about other NationalKidney Foundation resources, contact your

    local National Kidney Foundation affili-ate, or call the national toll-free number800.622.9010. Also, visit the Web site ofthe National Kidney Foundations Kidney

    Learning System atwww.kidney.org/KLS

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    NOTES

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    Stages of Kidney Disease

    Stage Description Glomerular Filtra-tion Rate (GFR)*1 Kidney damage (e.g., protein

    in the urine) with normal GFR 90 or above

    2 Kidney damage with milddecrease in GFR 60 to 89

    3 Moderate decrease in GFR 30 to 594 Severe reduction in GFR 15 to 295 Kidney failure Less than 15

    *Your GFR number tells your doctor how much kidney function you have.As chronic kidney disease progresses, your GFR number decreases.

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    National Kidney FoundationsKidney Disease OutcomesQuality Initiative

    Did you know that the National KidneyFoundations Kidney Disease OutcomesQuality Initiative (NKF-KDOQI) developsguidelines that help your doctor and

    health care team make important deci-sions about your medical treatment? Theinformation in this booklet is based onthe NKF-KDOQI recommended guide-lines for anemia, and it's very important

    for you to know.

    Stages of Chronic Kidney Disease

    There are five stages of chronic kidneydisease. They are shown in the table

    below. Your doctor determines your stageof kidney disease based on the presenceof kidney damage and your glomerularfiltration rate (GFR), which is a measureof your level of kidney function. Your treat-ment is based on your stage of kidneydisease. Speak to your doctor if youhave any questions about your stage ofkidney disease or your treatment.

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    More than 20 million Americansone in nine adultshave chronic kidneydisease, and most dont even know it. More than 20 million others are atincreased risk. The National Kidney Foundation, a major voluntary healthorganization, seeks to prevent kidney and urinary tract diseases, improve

    the health and well-being of individuals and families affected by thesediseases, and increase the availability of all organs for transplantation.Through its 47 affiliates nationwide, the foundation conducts programsin research, professional education, patient and community services,public education and organ donation. The work of the National KidneyFoundation is funded by public donations.

    www.kidney.org

    Education Along the Continuum of Care

    National Kidney Foundation30 East 33rd StreetNew York, NY 10016800.622.9010

    Light-shadedboxesindicatethescopeofcontentforthis KLSresource.GFR = GlomerularFiltrationRate; T = KidneyTransplant; D = Dialysis

    Also available in Spanish 11-50-0223 2006 National Kidney Foundation, Inc. All rights reserved. 11-50-0217

    The National Kidney Foundation gratefully acknowledges the sup-port for these KDOQI Guidelines and Recommendations providedby an educational grant from Amgen, Inc. and Roche.

    The National Kidney Foundation gratefully acknowledges the sup-port of Amgen, Inc., Founding and Principal Sponsor of KDOQI.