Question

CLINICAL SCENARIO:A. Patient’s ProfileName:Patient AndengBirthday: April 24,1931Age: 89 y/oSex:Female

Nationality:FilipinoReligion:Roman CatholicAddress:MalabonDate of Admission: Aug. 2,2020Time of Admission:11:30 PMChief Complaint: multiple vague physical and shortness of breathAdmitting Diagnosis: AnemiaHistory of Present IllnessPatient A's chief complaint is of feeling tired and short of breath at times. She also complains of arthritic pains in her neck and hands. Review of systems is notable for hearing loss, dentures, glasses, and dyspnea, mostly with exertion. She has occasional palpitations of the heart and orthopnea at times. Her bowel movements are regular, and she has not noticed any blood in the stool. She has 1+ chronic edema of the legs, which is about usual for her.Past Medical HistoryHer medical history is positive for congestive heart failure, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and osteoarthritis.During her last hospitalization, one year ago for pneumonia, the nephrologist and pulmonologist told Patient A there was not much else that could be done for her. Despite the poor prognosis, her multiple medical conditions stabilized and she completed a rehabilitation program. She enjoys participating in activities and has developed friendships with some other residents. Over the past year, she has been treated for multiple infections, including bronchitis and multiple urinary tract infections.Family History(+) HPN(+) Diabetes(-) Asthma(-) CancerAdmission OrderPatient A's chief complaint is of feeling tired and short of breath at times. She also complains of arthritic pains in her neck and hands. Review of systems is notable for hearing loss, dentures, glasses, and dyspnea, mostly with exertion. She has occasional palpitations of the heart and orthopnea at times. Her bowel movements are regular, and she has not noticed any blood in the stool. She has 1+ chronic edema of the legs, which is about usual for her. She has not had a mammogram for five years, and she has not had a dual energy x-ray absorptiometry scan, colonoscopy, or other preventive care recently.

Patient A's record indicates an allergy to sulfa drugs and penicillin. She also has completed advance directives (a do not resuscitate order and a living will). She is taking the following medications:Amlodipine besylate (Norvasc): 5 mg/dayCalcium carbonate (OsCal) with vitamin D twice dailyPolyethylene glycol powder (Miralax): 17 g in 8 oz liquid dailyFurosemide (Lasix): 40 mg/dayEscitalopram (Lexapro): 20 mg/dayPrednisone: 10 mg/dayOmeprazole (Prilosec): 20 mg/dayCinacalcet (Sensipar): 30 mg/daySimvastatin (Zocor): 20 mg at bedtimeTiotropium oral inhalation (Spiriva): 1 cap per inhalation device dailyVitamin B12: 1,000 mcg twice dailyEnteric-coated aspirin: 81 g/dayUpon physical examination, Patient A appears well-nourished and groomed. She is mildly short of breath at rest but in no apparent pain or distress. She is 5 feet 6 inches tall and weighs 156 pounds. Her vital signs indicate a blood pressure of 132/84 mm Hg; pulse 72 beats/minute; temperature 97.4 degrees F; respirations 20 breaths/minute; and oxygen saturation 94% on 2 L/minute. Her oropharynx is clear, and her neck is supple. There is no lymphadenopathy. The patient is hard of hearing and wears glasses for distance and reading.Patient A's heart rate is slightly irregular, with a soft systolic ejection murmur. Evaluation of her lungs indicates diminished breath sounds in the bases with no adventitious sounds. Abdomen palpation finds it to be soft and non-tender, with active bowel sounds and no signs of hepatosplenomegaly. As noted, Patient A has 1+ pitting chronic edema and vascular changes to lower extremities. There are no active skin lesions. Neurologic assessment shows no focal deficit. Extremity strength is rated 4 out of 5. A mini-mental status exam is administered, and the patient scores 22/30, indicating mild cognitive impairment.Blood is drawn and sent to the laboratory for CBC and a basic metabolic panel. The results are:Leukocytes: 5,700 cells/mcLRBC: 3.02 million cells/mcLHgb: 8.1 g/dLHCT: 25.2%MCV: 83 fLMCH: 26.5 Hgb/cellMCHC: 32%RDW-CV: 15.8%Platelets: 150,000 cells/mcLGlucose: 82 mg/dLBlood urea nitrogen (BUN): 34 mg/dLCreatinine: 1.4 mg/dL

GFR: 38 mL/minute/1.73 m2Patient A is in no apparent distress at present, but she appears to have anemia, as evidenced by the low Hgb. She has chronic kidney disease (stage 3), which may be contributing to the anemia. Further laboratory evaluation is necessary to determine the etiology of the anemia and to determine if specialty referral to gastroenterologist or hematologist is necessary. The clinician orders an iron profile, vitamin B12 and folate levels, reticulocyte count, and stool for occult blood. The resultsof this testing are:Vitamin B12: 1,996 pg/mLFolate: 9.9 mcMFerritin: 20 ng/mLSerum iron: 26 mcg/dLUnsaturated iron binding capacity: 216 mcg/dLTotal iron binding capacity: 242 mcg/dLTransferrin saturation: 11%Reticulocyte count: 1%Stool for occult blood: Negative (three samples)Vitamin B12 is a water-soluble vitamin that is excreted in urine, so a high level is generally not significant. The folate level is sufficient, while the ferritin level is considered low-to-normal. The iron profile shows a low level of iron in the blood; this may be caused by gastrointestinal bleeding or by inadequate absorption of iron by the body. Patient A has medical conditions that can cause elevated cytokines, which would interfere with iron absorption. If her ferritin level was high, which it is not, it would suggest AI/ACD. Therefore, the patient appears to have anemia secondary to chronic kidney disease.Prior to initiating treatment with an ESA, the patient is evaluated for a history of cancer, as these agentsmay cause progression/recurrence of cancer. Before writing the prescription for darbepoetin alfa, the clinician signs the ESA APPRISE Oncology Patient and Healthcare Professional Acknowledgement Form to document discussing the risks associated with darbepoetin alfa with the patient. The lowest dose that will prevent blood transfusion is prescribed.The multidisciplinary team works with Patient H to develop a treatment plan. It is determined that treating the anemia will improve the patient's quality of life. The patient is prescribed ferrous sulfate 325 mg twice daily. Because vitamin C facilitates iron absorption, the iron can be given with a glass of orange juice or other citrus juice (not grapefruit). Iron must not be given with calcium, milk products, and certain medications as they can interfere with absorption. The patient should be monitored for the development of constipation and the need for stool softeners. In addition, darbepoetin alfa 40 mcg is prescribed, to be administered subcutaneously every week. This requires significant monitoring. Hgb and HCT should be measured on the day patient is to receive the injection, and the drug should be held if the Hgb is greater than 11.5 g/dL. If a current Hgb level is unavailable, the drug should not be given.Blood pressure should be measured twice daily after treatment with darbepoetin alfa is initiated. Staff must also monitor for symptoms of a deep vein thrombosis and pulmonary embolus (e.g., unilateral edema, cough, and/or hemoptysis). Daily exercise is encouraged to help reduce the risk of a blood clot.

After one month, Patient A has received darbepoetin alfa weekly for four weeks. She is also taking the ferrous sulfate and a stool softener. The review of systems is unchanged from the previous evaluation.The physical examination is also unchanged aside from a 1-pound weight loss. No new complaints or problems are reported. A review of the patient's vital signs shows a blood pressure of 130/80 mm Hg; pulse 78 beats/minute; temperature 97.8 degrees F; and oxygen saturation 97 on 2 L/minute. Her Hgb levels over the last month have improved:Week 1: 8.4 g/dLWeek 2: 9.2 g/dLWeek 3: 9.6 g/dLWeek 4: 10.1 g/dLNo side effects as a result of the darbepoetin alfa are observed. Patient H's blood pressure remains stable, with no signs or symptoms of a blood clot.The clinician orders the weekly monitoring of Hgb and HCT to continue with the darbepoetin alfa held if the Hgb is greater than 11.5 g/dL. If the medication is held more than once, the clinician will re-evaluate the dosage and frequency. The patient may only need the injection once or twice a month after the anemia is stabilized. The clinician also reduces the patient's vitamin B12 supplement to daily (rather than twice daily) and reduces her prednisone dose to 5 mg/day.

PATHOPHYSIOLOGY OF ANEMIA SECONDARY TO CHRONIC KIDNEY DISEASE OR PATHOPHYSIOLOGY OF THIS CASE SCENARIO

Answer 1

Our kidney produces a hormone called erythropoietin(EPO). EPO makes red blood cells. when our kidney has a problem that can not make enough EPO, which causes low red blood cells and cause anemia. Anemia occurs in the initial stage when people with kidney anemia. Diabetes is one of the most common causes of chronic kidney failure. anemia make complications of CKD. anemia reduces the Hb concentration and kidney functions.patient with chronic kidney disease more prone to neuropathy, nephropathy, and retinopathy.
when a patient having diabetes that damage the tubulointerstitial damages that reduce the GFR. chronic renal failure cause respiratory complications and cause pulmonary edema, pulmonary calcification. fluid accumulation in the body can buildup in the lungs and cause a shortage of oxygen-carrying red blood cells that make the patient
have shortness of breath.COPD is common in patients with kidney failure they are more prone to cardiovascular disease. obstructive pulmonary function due to COPD due to increased systemic inflammation that increases the risk of CVD.