Iron metabolism. And. Anemia in chronic kidney disease

Transcription

1 Iron metabolism And Anemia in chronic kidney disease Chittima Sirijerachai

2 Iron distribution Intracellular iron Intracellular ferrous iron Heme iron compound : Hb, myoglobin Iron containing enzyme Intracellular ferric iron RE cell, heart, epithelial cell of small intestine Extracellular iron - Ferric-transferrin

3 utilization utilization Dietary iron 1-2 mg/day Bone marrow 300 mg Myoglobin 300 mg Plasma transferrin 3 mg Erythrocyte 1800 mg Liver 1000 mg Slough mucosal cell 1-2 mg/day Spleen 600 mg

4 Iron absorption Promote absorption -Fructose Fe +++ -Vitamin C -Heme iron -Amino acid Fe ++ Fe ++ HCl Inhibit absorption -Phosphate -Phytate Fe ++ ferritin -Tannin -Soil clay Fe transferrin

5 Iron absorption

6 Regulation of iron absorption Dietary iron mucosal block Iron stores store regulator Erythropoitic regulator

7 Iron utilization Heme

8 utilization Iron deficiency anemia utilization Dietary iron 1-2 mg/day Bone marrow 300 mg Myoglobin 300 mg Plasma transferrin 3 mg Erythrocyte 1800 mg Liver 1000 mg Slough mucosal cell 1-2 mg/day Spleen 600 mg

9 inflammation Anemia of chronic disease Liver hepcidin spleen hepcidin Plasma Fe-Tf rbc Bone marrow

10 Iron study Serum iron Total iron binding capacity (TIBC) Transferrin saturation (Tf sat) Ferritin

11 Iron depletion normal functional absolute erythrocyte Iron stores Serum ferritin (ng/ml) Tf sat % > 100 > 100 < 100 > 20 < 20 < 20

12 erythropoietin - iron - protein - etc Decreased production Blood loss Increased destruction

13 Causes of anemia in ESRD Decrease erythropoietin Iron deficiency Nutritional deficiency Decrease red cell survival Bone marrow suppression by uremia Osteitis fibrosa cystica Inflammation Aluminum toxicity

14 Work-up for a diagnosis of anemia in CKD Hb Adult male < 13.5 g/dl Adult female <12.5 g/dl

15 Diagnosis of renal anemia Significant impairment of renal function GFR < 30 cc/min, Cr > 2 mg/dl No other causes of anemia Iron deficiency anemia Nutritional deficiency anemia

16 Diagnosis of renal anemia History taking - Dietary intake - Chronic blood loss Physical examination

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18 Investigation CBC Red cell indices Iron study, ferritin

19 CBC and RBC indices fl pg g/dl %

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21 Iron study, ferritin TSAT < 20 % Ferritin < 100 ng/ml Iron deficiency anemia

22 Treatment of renal anemia

23 Benefit of anemia control in ESRD Increased survival Decreased cardiac complication Improved quality of life Increased exercise capacity Decreased hospitalization

24 Target for anemia treatment Hb > 11 g/dl Hct > 33 % Within 4 months Ferritin ng/ml TSAT %

25 Treatment of renal anemia Eryhtropoietin Iron therapy Adequate dialysis Nutritional support

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27 Iron therapy Improved response to EPO Reduced dose of EPO

28 Iron therapy Iron sucrose (venofer) VS Oral iron IV iron

29 Iron therapy - Ferrous sulfate 1 x 3 - Iron sucrose mg/wk Monitor:- serum ferritin, TSAT q 1-3 months

30 Iron therapy in CKD Serum ferritin < 100 ng/ml - iron deficiency > 800 ng/ml - stop iron Rx Transferrin saturation < 20 % - iron deficiency > 50 % - stop iron Rx

31 Side effects of iron therapy Oral iron - GI irritation - Diarrhea - Constipation IV iron - anaphylactoid - hypotension - muscle cramp

32 Erythropoietin Erythropoietin α Erythropoietin β Eprex Eporon Epokrine Recormon

33 Erythropoietin U/kg/wk SC U/kg/wk IV Hb 1-2 g/dl/month

34 Erythropoietin Side effects - hypertension - headache -PRCA - Thrombosis

35 Inadequate erythropoietin response Patient fail to attain the target Hb while receiving:- EPO 300 U/kg/wk SC EPO 450 U/kg/wk IV 4-6 months

36 Inadequate erythropoietin response Iron deficiency anemia Chronic blood loss Chronic inflammation Inadequate dialysis hyperparathyroidism

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