Anemia management: a story of sleuthing.

ESA therapy is commonly initiated when the Hgb is less than 11 g/dL. The shared hope and expectation as we partner with patients and their families in the plan of care is that the way to attain intended outcomes will be clear and involve no mystery. It can be surprising and challenging when those outcomes are not easily met. Mr. I achieved the targets for TSAS and ferritin levels, and both he and his significant other demonstrated knowledge about anemia and its ramifications and skill in the administration of the ESA. However, during the time he was enrolled in the CKD anemia management program, he did not achieve or maintain a Hgb between 11.0 and 12.0 g/dL. What are the lessons learned and implications for nephrology nurses? Be specific with patients about their medications. Ask about injectable and intravenous medications, radiotherapy, drugs that affect DNA synthesis (such as chemotherapeutic drugs), street drugs, herbal therapies, and vitamins. Be thorough when obtaining a medical and lifestyle history, especially as it relates to conditions that may affect erythropoiesis, for example, is the patient smoking? How much alcohol does he drink? Has he seen a Healthcare provider for any old or new problems recently? In addition, patients with CKD have many co-morbidities, which may include cancer. ESA therapy becomes much more complex in the patient with cancer and CKD, and therapy may necessitate a different approach and different Hgb targets. Finally, nurses must be diligent and methodical in the quest to uncover the reasons for hyporesponsiveness in the patient with CKD who has anemia.