UNDERSTANDINGUnderstanding IRONYour AND CHRONIC KIDNEYHemodialysis DISEASE Access Options

UNDERSTANDING AND CHRONIC KIDNEY DISEASE WHAT IS CHRONIC KIDNEY may begin to feel the effects of DISEASE (CKD)? anemia. When someone has CKD, it WHAT IS ANEMIA? means that their kidney function Our blood is made up of mainly has slowed down. These changes red blood cells, white blood usually take place over time. cells and platelets. When a There are a variety of diseases person has anemia, it means or conditions that can lead to that they have fewer red blood CKD. Two of these are diabetes cells than normal and may not and high blood pressure. A lot have enough iron. Why is that of people have those diseases important? Red blood cells carry and are at risk for CKD. Other oxygen throughout the body. diseases present at birth can Organs and tissues need oxygen cause CKD. Among them are to function and stay healthy. So, Polycystic Kidney Disease, fewer red blood cells cause low Alport Syndrome, Fabry disease oxygen and low oxygen makes among others. us feel weak and tired. There are five stages of CKD. The stages show how well the WHAT DOES CKD HAVE kidneys are doing their job. Your TO DO WITH ANEMIA? healthcare provider can do a The kidneys make a hormone to see what stage you called erythropoietin (er-wreath- are in. In Stage 1, there is very ro-po-i-tin). Often it is called little kidney damage. By Stage 5, EPO for short. EPO coupled with the kidneys will have lost most iron makes red blood cells in the of their function. Even though bone marrow. CKD affects the complications due to CKD, such amount of EPO that the kidneys as anemia, can start as early make. As kidney function gets as CKD stage 3, more serious worse, in the later stages of CKD, symptoms of anemia usually the ability for the kidneys to become more noticeable in CKD produce EPO decreases. Patients stage 5. Ask your healthcare whose kidneys are not making provider to check your blood enough EPO will need an to see if you have any signs of erythropoietin stimulating agent anemia and/or low levels of (ESA) therapy prescribed by iron. If the kidneys continue their physician. Like naturally to lose function, most people produced EPO, this ESA therapy will have signs of anemia. Some will also need iron to make red blood cells.

American Association of Kidney Patients: Understanding Iron and Chronic Kidney Disease 3 Dialysis patients can lose blood The symptoms may be a lot during dialysis treatments as like those for other diseases. well as due to more frequent This can make it hard to tell if blood testing. Not receiving the way you feel is just due to enough ESA therapy and having anemia. Here are some ways a low iron level (not replacing people say they feel when they that lost iron) is the main reason have anemia. dialysis patients suffer from anemia. • I never have enough energy • I feel weak • I feel tired • It’s hard to concentrate, I feel like I have “brain fog” • It feels like my heart is beating too fast • Sometimes my heart skips beats • I get short of breath • I am having headaches • I am not sleeping very well • My appetite does not seem to be as good as it once was • My hands and feet won’t stay warm • I may feel dizzy • I sometimes feel sad or “down in the dumps” • It’s hard to do everyday tasks like make a sandwich or walk up stairs DOES ANEMIA EFFECT Some people don’t have any HOW I FEEL? symptoms at first. However, as If you have anemia, you may anemia gets worse, a person have a variety of symptoms. may start having more and more of these symptoms.

4 American Association of Kidney Patients: Understanding Iron and Chronic Kidney Disease How can I find out if I have The CBC also measures: anemia? • The levels of the different If you have any or many of these cells in your blood symptoms it may be because: • The number, type, size and • Your body is not naturally shape of the cells in your producing enough EPO; blood • If you are prescribed an ESA Two of the tests therapy, you may not getting are: enough ESA therapy; • (Hgb) is part of • Your iron levels may be low; the blood cell that contains • You may not be getting the iron that takes oxygen to enough dialysis; or tissues and organs. • You may have an infection • (Hct) tells how or inflammation. many cells are in a certain amount of blood. This can be used to tell if the number of So whether you are on dialysis red cells in the blood is too or not, a thorough check-up is low, just right or too high. recommended. Target hemoglobin value: If you have any of the symptoms of anemia, tell the healthcare The optimal target Hgb level professional who is doing your for patients with CKD is not check-up. Your check-up should well defined or “one size fits include: all”. In patients with CKD on dialysis or not on dialysis, • Questions to find out how anemia treatment should be you are feeling right now individualized. A patient’s target • Current health history Hgb level should be determined • Past health history based on a discussion between the patient and their physician • Medication review as to what is best for him/her • Physical exam and how he/she feels and can • Urine test if indicated function on a daily basis at various Hgb levels. • Blood tests For most CKD patients not on The or dialysis, who are anemic and CBC is the main test that tells if a are on ESA therapy, Hgb levels person has anemia.

American Association of Kidney Patients: Understanding Iron and Chronic Kidney Disease 5 should be maintained between • Kidney function if indicated 10-11.5 g/dL using the lowest • Vitamin B12 level ESA dose. The U.S. Food and Drug Administration (FDA) • Folic acid level approved label on ESAs states • Changes in the blood related that, for patients with CKD who to other diseases are not on dialysis, one should consider ESA treatment only HOW IS LOW IRON when the Hb level is <10 g/dL TREATED? and reduce or stop the ESA dose If the iron level is low, the if the Hgb level exceeds 10 g/dL. first step in treating anemia In most dialysis patients who is to raise the iron level. How are anemic and are treated and where this is done may with an ESA therapy, Hgb levels depend on the level of kidney should be maintained between function. The approaches are 10 -11.5 g/dL, using the lowest different for those with CKD not ESA dose. doing dialysis than those doing Other blood tests are done to dialysis. The type of dialysis and check how much iron is in the the place where it is done may body. Those tests are: play a part too. • iron – level of iron Patients with CKD not on circulating in the blood dialysis: • Serum – amount of Your healthcare provider should iron stored in the body and check iron levels and if low, will inflammation likely prescribe oral iron pills (iron pills take by the mouth). • saturation or If iron pills do not increase TSAT – amount of iron that is your iron level, you may need bound to transferrin and can intravenous iron (iron shot in be used to make red blood the vein). If your Hgb is still low cells after iron shots, you may need Based on the results of these an ESA therapy to replace your tests, your healthcare provider body’s natural production of may decide that you need to EPO. ESA shots are like a person have more iron. taking insulin shots for diabetes. But before deciding to give iron, Your healthcare provider should they may do additional tests routinely check your Hgb and including:

6 American Association of Kidney Patients: Understanding Iron and Chronic Kidney Disease iron levels to adjust iron and ESA mixed into a patient’s dialysis doses as needed. fluid (dialysate) and delivered Patients with CKD on peritoneal during treatment. This dialysate dialysis or home hemodialysis: iron therapy does not require iron to be given intravenously, so Similar to patients with CKD who no needles are involved. are not on dialysis, home dialysis patients should regularly have Be sure to ask your healthcare their Hgb and iron levels checked. provider about all available iron If a home dialysis patient has low therapies and discuss which iron levels, they should start an treatment is best for you. iron therapy and if Hgb remains CAN I GET IRON FROM low, they should be started on an ESA therapy. FOOD? Patients with CKD on There are foods rich in iron. Some hemodialysis: are not kidney-friendly. If you have a dietitian, ask them about Hemodialysis patients tend to the foods you can eat. If you don’t lose more iron and have low iron have access to a dietitian, ask levels. This is due to blood loss your healthcare provider to help during hemodialysis because of you with this. But you should waste during dialysis treatment know that iron just from food as well as due to more frequent will not be enough to give you the blood testing. Most, if not all, amount of iron you need. of patients on hemodialysis require iron treatment, usually given intravenously, in the machine. More recently a new therapy has been approved by the FDA and has become available for patients on hemodialysis. The new iron therapy is

American Association of Kidney Patients: Understanding Iron and Chronic Kidney Disease 7 QUESTIONS ABOUT IRON YOU MAY WANT TO ASK YOUR HEALTHCARE TEAM

1. What tests are done to check my iron level?

2. What do my iron tests show?

3. Do the tests show that I need an iron therapy?

4. How do you decide what type of iron therapy I need to take?

5. Can I use iron pills?

6. If I can’t take pills, how will iron be given to me?

7. Can I get the iron during my dialysis treatments?

8. How will I get iron if I am on hemodialysis?

9. How will I get iron if I am on a home dialysis therapy?

10. How will I get iron if I am not on dialysis?

11. Are there side effects from iron therapies?

12. Can I get too much iron?

13. How long will I have to take iron therapy?

14. How often will you check my iron level?

15. Will you go over the test results with me?

8 American Association of Kidney Patients: Understanding Iron and Chronic Kidney Disease SUMMARY

• The body needs iron to make hemoglobin so the red blood cells in the blood can carry oxygen to tissues and organs.

• Low iron is a factor in the anemia of chronic kidney disease. You may need to take an erythropoetin stimulating agent (ESA) therapy if your body is not producing enough natural erythropoietin (EPO). Your healthcare provider will look at the whole picture and work with you to develop the best approach to optimal care.

• There are different types of iron medications and preparations.

• Iron pills don’t work well for patients on dialysis or with advanced CKD.

• The decision for what type of iron is used in a dialysis clinic is made by the dialysis care team.

• The dose of iron, how it’s given to you and how often it is prescribed is based on what the patient needs.

• Most hemodialysis patients will get iron therapy during their dialysis treatments.

• Patients doing home dialysis and those with advanced CKD may get iron via a shot or an IV.

• Iron from kidney-friendly foods may help but won’t be enough to treat a low iron level and anemia.

To learn more about anemia, read the AAKP Understanding Anemia of Chronic Kidney Disease brochure by visiting www.aakp.org or calling (800) 749-2257 to request a copy.

American Association of Kidney Patients: Understanding Iron and Chronic Kidney Disease 9 WORDS TO KNOW

• Erythropoietin: A hormone produced by the kidney that helps the development of red blood cells by the bone marrow.

• Erythropoietin Stimulating Agent: A therapy commonly used to treat anemia associated with chronic kidney disease when the kidney is not producing enough erythropoietin naturally.

• Hemoglobin: The molecule in red blood cells that carries oxygen. NOTES

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