Anemia Management: Hematinics

Summary This small randomized controlled trial (n=42) in hemodialysis patients on erythropoietin (EPO) and intravenous iron with refractory anemia and hyperferritinemia found that intravenous vitamin C improved EPO responsiveness, achieved significant increases in hemoglobin, and enabled EPO dose reduction. Patients meeting inclusion criteria were randomly assigned to one of two groups: A treatment group (n=20) to received standard care (EPO plus IV iron) and 300 mg IV ascorbic acid with each dialysis session, and a control group (n=22) to receive standard care.

Summary Cuenca et al investigated the use of preoperative hematinics in addition to a restrictive transfusion protocol to reduce transfusion requirements in patients undergoing total knee replacement. When compared with a control group, preoperative hematinics reduced transfusion requirements in both anemic and non-anemic patients. All patients scheduled for primary unilateral total knee replacement (TKR) during a 12-month period who met inclusion criteria were enrolled in the study group (n=156). A previous series of 156 patients meeting study criteria served as the control group.

Summary Anemia is the most common hematologic disorder and may be classified as acquired or inherited, or according to the mechanism of decreased RBC production or increased RBC destruction, or by mean corpuscular volume (MCV). During pregnancy, iron needs increase because blood volume expands by ~ 50% and total RBC mass expands by ~25%. Normal iron indices during pregnancy are: plasma iron level, 40-175 µg/dL; plasma total iron-binding capacity, 216-400 µg/dL; transferrin saturation, 16-60%; serum ferritin level, >10 µg/dL; and free RBC protoporphyrin level <3 µg/g.

Summary Anemia of chronic disease (ACD) is a hypoproliferative disorder that develops as a response to systemic illness or inflammation. Traditionally, it was thought to be an adverse consequence of systemic illness. However, Zarychanski and Houston believe that ACD is an adaptive response to an underlying disease state and support this argument in this article. Anemia in these circumstances is thought to be deleterious because the decrease in RBCs causes a decrease in oxygen-carrying capabilities and anemia is connected to a poor prognosis in many clinical disorders.

Summary Erythropoiesis-stimulating agents (ESAs) and IV iron products have had a great impact on nephrology. RBC production is controlled by erythropoietin (EPO) and the hormone is produced de novo in the kidney in response to hypoxia. EPO replacement therapy became the mainstay of treatment for patients on dialysis who required many transfusions. Simultaneously, clinicians began to recognize the importance of iron supplementation in anemia management and a need for IV iron products was voiced.

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