NU-623 Herzing University – A 65-year-old woman presents to the office with complaints of excessive fatigue and shortness of breath after activity, which is abnormal for her

A 65-year-old woman presents to the office with complaints of excessive fatigue and shortness of breath after activity, which is abnormal for her. The woman has a history of congestive heart failure with decreased kidney function within the last year. The woman appears unusually tired and slightly pale. Additional history and examination rules out worsening heart failure, acute illness, and worsening kidney disease. The complete blood count (CBC) results indicate that hemoglobin is 9.5 g/dL, which is a new finding, and the hematocrit is 29%. Previous hemoglobin levels have been 11 to 13g/dL. The patient’s vital signs are temperature 98.7°F, heart rate 92 bpm, respirations 28 breaths per minute, and blood pressure 138/72. The practitioner suspects the low hemoglobin level is related to the decline in kidney function and begins to address treatment related to the condition.

Should the practitioner consider a blood transfusion for this patient? Explain your answer.

Which medication(s) should be considered for this patient? Provide exact prescription details.

What considerations should the practitioner include in the care of the patient if an erythropoietic agent is used for treatment?

ANSWER

Management of Anemia in a Patient with Decreased Kidney Function: Considerations for Blood Transfusion and Erythropoietic Agents

The practitioner should consider a blood transfusion for this patient due to her symptoms of excessive fatigue and shortness of breath, along with the significant decline in hemoglobin levels. Hemoglobin is a vital component of red blood cells responsible for carrying oxygen throughout the body. A low hemoglobin level, such as the one observed in this case (9.5 g/dL), indicates anemia, which can lead to reduced oxygen delivery to tissues and organs.

In this particular patient, the decline in kidney function could be contributing to the low hemoglobin levels. The kidneys play a crucial role in the production of erythropoietin, a hormone that stimulates the bone marrow to produce red blood cells. Reduced kidney function can lead to decreased erythropoietin production, resulting in anemia.

Considering the patient’s symptoms, history of congestive heart failure, and the significant drop in hemoglobin levels, a blood transfusion may be necessary to promptly raise her hemoglobin levels and alleviate symptoms (Lotterman, 2022). Blood transfusions involve the administration of donated blood or blood products to increase the number of red blood cells and improve oxygen-carrying capacity.

The choice of medication(s) for this patient should be aimed at addressing the underlying cause of anemia, which is decreased erythropoietin production due to kidney dysfunction. In such cases, erythropoietic agents are commonly used to stimulate red blood cell production.

One specific medication that can be considered is erythropoietin-stimulating agents (ESAs). These agents work by mimicking the action of erythropoietin, thereby stimulating the bone marrow to produce more red blood cells. An example of an ESA that could be prescribed for this patient is “Darbepoetin alfa 200 mcg subcutaneously once weekly.” The exact prescription details may vary based on individual patient factors, such as weight, renal function, and response to treatment (PRIME PubMed | Darbepoetin Journal Articles From PubMed, n.d.). Therefore, it is important for the practitioner to evaluate these factors and adjust the dosage accordingly.

When using erythropoietic agents for the treatment of anemia, the practitioner should consider several important considerations in the care of the patient:

Monitoring: Regular monitoring of hemoglobin levels is essential to evaluate the response to treatment. The goal is to maintain hemoglobin levels within the target range, usually around 10-12 g/dL, to optimize oxygen delivery while avoiding excessive levels that may increase the risk of adverse events.

Iron supplementation: Adequate iron stores are necessary for the production of red blood cells. Prior to initiating erythropoietic agents, the practitioner should assess the patient’s iron status (Jimenez, 2015). If iron deficiency is present, oral or intravenous iron supplementation may be required to optimize the response to treatment.

Blood pressure monitoring: Erythropoietic agents can sometimes increase blood pressure. Therefore, it is crucial to monitor blood pressure regularly during treatment. In patients with a history of hypertension, blood pressure control should be optimized before initiating therapy.

Thromboembolic events: There is a potential risk of thromboembolic events with the use of erythropoietic agents. The practitioner should assess the patient’s risk factors for thrombosis and use caution in patients with a history of cardiovascular disease or venous thromboembolism.

Individualized treatment approach: The dosage and frequency of erythropoietic agents should be tailored to the patient’s specific needs. Factors such as renal function, response to therapy, and the presence of comorbidities should be considered when determining the optimal treatment regimen.

In summary, for this patient presenting with fatigue, shortness of breath, and a significant decline in hemoglobin levels related to decreased kidney function, a blood transfusion should be considered to promptly address the anemia and alleviate symptoms. Additionally, the use of erythropoietic agents, such as darbepoetin alfa, may be appropriate for long-term management. However, the specific prescription details should be based on individual patient factors, and careful monitoring and considerations are necessary when using erythropoietic agents to optimize patient care and outcomes.

References

Jimenez, K. (2015, April 1). Management of Iron Deficiency Anemia. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4836595/ 

Lotterman, S. (2022, June 25). Blood Transfusion. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK499824/ 

PRIME PubMed | darbepoetin journal articles from PubMed. (n.d.). https://www.unboundmedicine.com/medline/research/darbepoetin