Information for patients about anaemia and its treatment

Introduction

If you are on dialysis, you are likely to have anaemia, a decrease in the amount of haemoglobin found in the bloodstream. Anaemia can make you feel very weak and tired.

This leaflet will tell you what anaemia is, why it occurs and what treatment is available to control it

What is anaemia?

Oxygen is carried around the body by a substance called haemoglobin which is found in the red blood cells of the blood. If you do not have enough haemoglobin, your blood is unable to carry enough oxygen around the body. It is the reduction in the amount of oxygen going around the body that causes the symptoms of anaemia. Anaemia can occur for several different reasons, for example: after operations; during pregnancy; because of blood loss from an ulcer or not having enough iron in your diet.

How do I know if I have anaemia?

The symptoms appear gradually. You might feel more tired or lethargic. You will have less energy to do things. You might feel the cold more easily and feel out of breath doing things that do not normally make you breathless.

What causes anaemia in kidney failure?

Red blood cells are made in the bone marrow. Red blood cells are constantly being produced to replace those that are lost or die. These cells contain haemoglobin which carries oxygen. When the number of these cells drops in the bloodstream, less oxygen can be carried around the body causing anaemia.

The production of red blood cells is controlled by a hormone called erythropoietin (EPO). The kidneys make EPO in response to the level of oxygen in the bloodstream, the less oxygen from fewer red blood cells, the more EPO produced. In kidney failure, your kidneys cannot respond in this way and are unable to produce sufficient amounts of EPO when lower oxygen levels are detected.

To find out if you are anaemic, your doctor will order a blood test to measure your haemoglobin. This tells your doctor whether or not your are anaemic by measuring the amount of haemoglobin in your blood and if you need treatment. Chronic renal failure patients often have haemoglobin levels well below normal.

How is anaemia in chronic renal failure treated?

If you have kidney failure, it is likely that this is the cause of your anaemia. However, there other causes of anaemia and they need to be ruled out by investigations or treated.

If your anaemia is caused by kidney failure, your doctor may give you EPO, an artificial form of the natural hormone. You may also require an iron supplement.

How is EPO made?

EPO is made outside of the body, in the laboratory, using genetic engineering. Artificial EPO is identical to the EPO our kidneys produce and acts in the same way, stimulating red blood cell production.

How do I take EPO?

If you are to start EPO you will be given advice and support by an EPO co-ordinator or a link nurse specialising in this treatment type. The nurse will be able to tell you about the treatment and answer your questions.

EPO is given as a subcutaneous (under the skin) injection. Most people are able to give this injection to themselves once they have had some practice and got the hang of it. The best places for these injections are in the thigh or tummy. Usually, you will need about 2 or 3 injections a week. Some people have their EPO given during dialysis.

All the equipment you need will be supplied to you, including sharps boxes to put used needles in. EPO needs to be kept refrigerated until half an hour before you use it, to give it time to warm up to room temperature.

How long before I feel better?

Your doctor will prescribe enough EPO to gradually increase your haemoglobin levels closer to normal. The aim is usually for a haemoglobin level of at least 10 g/dl. This may take weeks or months. Your improvement will be gradual, it takes time for the new red blood cells to replace the lost cells. Once your haemoglobin is stabilised your doctor may need to adjust your dosage. You may not need as much EPO or to take it as frequently. Occasionally, a break from EPO may be possible. However, as long as you have kidney failure, the anaemia is likely to return when treatment is discontinued. Regular blood tests will be required to monitor progress.

What are the side-effects from taking EPO?

EPO generally causes few problems. However, some side-effects have been noted. Blood pressure rises are the most important. You will need to have your blood pressure monitored regularly from the beginning of your EPO treatment. In the beginning, just once or twice a week. If your blood pressure goes up consistently, it will need to be treated and any existing medicines you are taking for high blood pressure may be adjusted. If you get bad headaches when you take your EPO, please tell your nurse or doctor. This may be a symptom of high blood pressure.

Some people have also experienced ‘flu like symptoms after injection and for a few days. Occasionally, a rash or redness is noted around the injection site but usually clears up quickly.

Iron therapy

Iron is a vital building block in the production of red blood cells. Unfortunately, a little iron is lost during each haemodialysis session contributing to anaemia in kidney failure. Peritoneal dialysis patients can also suffer from iron deficiency. You may already be taking an iron supplement. When treatment with EPO is started the body uses up its remaining store of iron very quickly. Without extra iron, the EPO may not work properly. Iron can be prescribed as a tablet or given intravenously if necessary.

How do I know if I have enough iron?

A blood test will indicate if you are lacking enough iron. On the basis of this test, your doctor will prescribe either tablets or injections given intravenously (if you are on haemodialysis this can be given during a session). Patients who are not on dialysis or CAPD may receive intravenous iron on a weekly basis in the renal unit.

What side effects does iron therapy have?

It may be necessary to try different amounts and kinds of iron supplements before the right dosage is found. Iron tablets may cause stomach problems such as loose stools, diarrhoea, constipation and stomach aches. If you have stomach problems caused by iron tablets, please tell your doctor. Do not take iron tablets with milk or tea or at the same time of day as antacids, titralac and calcichew. These medicines will interfere with the body’s ability to absorb the iron.

Do I need to take anything else?

Vitamin B and Folic Acid also help in red blood cell production and may be prescribed by your doctor.

What are the benefits of these treatments?

The chief benefit of EPO and Iron treatments is that they are effective in treating the symptoms of anaemia. Many patients notice a great difference in the way they feel, having more energy and better levels of concentration. In addition, these patients may not need blood transfusions to correct their anaemia.

Taking EPO will not affect your need for dialysis. But it should improve your quality of life on dialysis.

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