The program will provide information on the evaluation and management of anemia of chronic kidney disease (CKD) in the long-term care setting. It will include information on the prevalence, risks, and comorbidities of anemia of CKD; why the management of anemia is important; and management and monitoring skills.
FACULTY
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Michael R. Wasserman, MD (Program Chair) Medical Director Senior Care of Colorado, PC Aurora, Colorado Assistant Clinical Professor of Medicine University of Colorado Health Science Center Denver, Colorado |
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Barbara M. Resnick, PhD,
CRNP, FAAN, FAANP
Professor of Nursing University of Maryland School of Nursing Baltimore, Maryland |
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Peter H. Juergensen, PA-C Physician Assistant Metabolism Associates New Haven, Connecticut Assistant Clinical Professor Yale University School of Nursing |
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AGENDA
Overview of Anemia of CKD: Long-Term Care Perspectives
Peter H. Juergensen, PA-C
Evaluation of Anemia of CKD in Long-Term Care
Barbara M. Resnick, PhD, CRNP, FAAN, FAANP
Anemia of CKD in Long-Term Care: Management and Monitoring Skills
Michael R. Wasserman, MD
Case Study Discussion
All faculty
NEEDS ASSESSMENT
The incidence of anemia, a condition involving low hemoglobin (Hgb) concentration, typically increases with advancing age. It is particularly common among elderly residents of long-term care facilities and affects an estimated 24% to 40% of hospitalized patients older than age 65.1,2 In one study, the prevalence of anemia in both male and female long-term residents over age 70 was 4 times that reported in a previous study of older community dwellers.3 Anemia is associated with cerebrovascular and cardiovascular diseases and a greater risk for falls and fractures.4-6
Anemia is defined by the Kidney Disease Outcome Quality Initiative (KDOQI) guidelines as Hgb <13.5 g/dL in males and <12.0 g/dL in females.7 Types of anemia include megaloblastic anemia, myelodysplasia, anemia of chronic disease or inflammation, and anemia of chronic kidney disease (CKD).
The anemia of CKD, involving impaired erythropoietin production, is more severe than other forms of anemia and can lead to cardiovascular complications and death.8,9 The most prevalent type of anemia in patients >85 years, it typically does not respond to iron, folate, or vitamin B12 supplementation and is best treated with synthetic erythropoietin-stimulating agents (ESAs). The anemia of CKD can also contribute significantly to cerebrovascular diseases, fatigability, impaired cognition, poor muscle strength, and diminished mobility.
The anemia of CKD is under-recognized and undertreated, perhaps because its associated symptoms are nonspecific and may be mistakenly assumed to be the results of aging.10 To diagnose CKD, the glomerular filtration rate (GFR) is measured to assess renal function. A GFR <60 mL/min/1.73 m2 for ≥3 months or the presence of any kidney damage indicates CKD. The stage of CKD (Stages 1-5, from mild disease to kidney failure) also must be determined.7
After CKD has been diagnosed, if Hgb levels are <12.0 g/dL, a work-up should be done and complete blood count, total iron-binding capacity, and transferrin saturation measured. If the patient’s normal Hgb level is <11 g/dL, ESA therapy should be given as indicated. If it is >11 g/dL, the patient should be assessed for an iron deficiency.11 Patients with the anemia of CKD need iron replacement therapy in addition to ESA therapy.
Early correction of anemia can slow the progression of CKD and reduce overall morbidity, mortality, and the high costs of hospitalizations and long-term care.12 Epoetin alfa and darbepoetin alfa, while efficacious, are associated with high costs, a greater risk for serious cardiovascular events and death, and the risk for more rapid tumor growth or shortened survival in patients with breast, non-small cell lung, head and neck, lymphoid or cervical cancers. However, the risk for adverse effects can be greatly reduced by selecting an Hgb target level in the range of 11.0 to 12.0 g/dL.13 According to the KDOQI workgroup, Hgb levels should not exceed 13.0 g/dL.
Extended dosing can reduce the high costs of treatment for this chronic disease, as it involves fewer patient visits, injections, and supplies and less demand on staff and treatment facilities. Epoetin α was initiated safely and effectively at an extended dosing interval of 20,000 IU every 2 weeks in CKD patients not on dialysis.14 Average Hgb levels
≥11.0 g/dL were maintained in about 90% of patients dosed once every 2 weeks and in >75% of patients dosed once every 3 or 4 weeks.15
Through an educational program providing updated information on the evaluation and management of the anemia of CKD in the long-term care setting, nurse practitioners and physician assistants can help to improve clinical outcomes for their patients with this condition.
| 1. | Wu WC, Rathore SS, Wang M, et al. Blood transfusion in elderly patients with acute myocardial infarction. N Engl J Med. 2001;345:1230-1236. |
| 2. | Artz A, Fergusson D, Drinka PJ, et al. Prevalence of anemia in skilled-nursing home residents. Arch Gerontol Geriatr. 2004;39:201-206. |
| 3. | Pandya N, Bookhart B, Mody SH, et al. Study of anemia in long-term care (SALT) - prevalence of anemia in nursing home residents: Relationship with resident characteristics and comorbidities. J Am Med Dir Assoc. 2007;8:B20. |
| 4. | Wilson A, Ershler WB. Prevalence and outcomes of anemia in geriatrics: a systematic review of the literature. Am J Med. 2004;116:3S-10S. |
| 5. | Dharmarajan TS, Avula S, Norkus EP. Anemia increases risk for falls in hospitalized older adults: an evaluation of falls in 362 hospitalized, ambulatory, long-term care, and community patients. J Am Med Dir Assoc. 2006;7:287-293. Epub 2006 Feb 3. |
| 6. | Guralnik JM, Eisenstaedt RS, Ferrucci L, et al. Prevalence of anemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anemia. Blood. 2004;104:2263-2268. |
| 7. | National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease. Am J Kidney Dis. 2006;47(suppl S3):S17-S85. |
| 8. | Go AS, Chertow GM, Fan D, et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med. 2004;351:1296-1305. |
| 9. | John R, Webb M, Young A, et al. Unreferred chronic kidney disease: a longitudinal study. Am J Kidney Dis. 2004;43:825-835. |
| 10. | Morley JE, Hoggard J, Geronemus RP, et al. Diagnosis and Management of Anemia in Long-Term Care. Ann Long Term Care. 2003. August:S1-S21. |
| 11. | KDOQI; National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease. Am J Kidney Dis. 2006;47(5 suppl 3):S11-S145. |
| 12. | Bedani PL, Verzola A, Bergami M, et al. Erythropoietin and cardiocirculatory condition in aged patients with chronic renal failure. Nephron. 2001;89:350-353. |
| 13. | National Kidney Foundation. National Kidney Foundation Releases Preliminary Anemia Guideline Update. Available at: http://www.kidney.org/news/newsroom/newsitem.cfm?id=380. Accessed August 23, 2007. |
| 14. | Benz R, Schmidt R, Kelly K, Wolfson M. Epoetin alfa once every 2 weeks is effective for initiation of treatment of anemia of chronic kidney disease. Clin J Am Soc Nephrol. 2007;2:215-221. |
| 15. | Provenzano R, Bhaduri S, Singh AK, et al. Extended epoetin alfa dosing as maintenance treatment for the anemia of chronic kidney disease: the PROMPT study. Clin Nephrol. 2005;64:113-123. |
LEARNING OBJECTIVES
Upon completion of this activity, participants should be better able to:
| • | Cite the incidence, prevalence, risks, and comorbidities of the anemia of chronic kidney disease (CKD) in long-term care settings |
| • | Explain why the management of anemia is important |
| • | Describe the evaluation of anemia of CKD in long-term care settings |
| • | Describe management and monitoring skills for treating the anemia of CKD in long-term care settings, including cost, benefits, and risks of treatment |
TARGET AUDIENCE
Physician assistants (PAs) and nurse practitioners (NPs) working in long-term care
SPONSORSHIP AND APPROVAL INFORMATION FOR PHYSICIAN ASSISTANTS
This program has been reviewed and is approved for a maximum of 1 hour of AAPA category 1 (preapproved) CME credit by the Physician Assistant Review Panel. Approval is valid for 1 year from the issue date of September 2008. Participants may submit the self-assessment at any time during that period. This program was planned in accordance with AAPA’s CME Standards for Enduring Material Programs and for Commercial Support of Enduring Material Programs.
ACCREDITATION STATEMENT FOR NURSE PRACTITIONERS
This program has been approved for 1.0 contact hour of continuing education by the American Academy of Nurse Practitioners. Program ID 0807347
DISCLOSURE POLICY
It is the policy of AAPA and AANP to ensure balance, independence, objectivity, and scientific rigor in all its educational activities. All participating faculty in our programs are expected to disclose any relationships they may have with commercial companies whose products or services may be mentioned. In addition, any discussion of off-label, experimental, or investigational use of drugs or devices will be disclosed by the faculty.
FACULTY DISCLOSURES
The faculty for this program reported the following financial relationships with commercial interests:
Dr. Wasserman has served on the speakers’ bureau for Ortho McNeil.
Dr. Resnick has served as a consultant and is on the speakers’ bureaus for Amgen and Ortho Biotech.
Mr. Juergensen has served on the speakers’ bureaus for Abbott Laboratories, Amgen, and Watson
Pharmaceuticals, Inc.
GRANT SUPPORT
This program has been supported by an educational grant from Ortho Biotech, Inc.
