Anaemia, heart failure and CKD (21)

This elderly man has multiple medical problems.  His main current problem is heart failure – he has moderate LV dysfunction, valvular heart disease and pulmonary hypertension.  He is seen by the Heart Failure Nurse and we have reached the point where we agree his treatment is palliative.  He gets recurrent peripheral oedema and ascites.  His renal function shows a urea of around 20 and creatinine of around 200.  At home he is able to walk with a frame from his bedroom to the living room but this makes him breathless.  He is a type 2 diabetic and also has mild memory impairment.

He has had a chronic long standing anaemia over a number of years.  This has seen his haemoglobin slide from the 10.3 down to 8.3 when last checked.   He had GI investigations and was found to have a number of polyps and an area of angiodysplasia.  He has had a couple of transfusions.  It was decided earlier this year that further investigation was not appropriate.  He is on iron so it is difficult to know how much of his anaemia is due to his renal problems.

When discharged last week it was suggested that we should contact you about erythropoietin treatment.  Improvement of his anaemia might help his heart failure a little though I suspect this would only be temporary.  He is very frail and clinic attendance might not be possible.  I would be grateful for your advice

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Current medications include: bumetanide 5mg OD, metolazone 2.5mg once weekly and insulin.



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There are 2 issues here:

1. Anaemia & EPO – the advice given to you is a bit misleading.  EPO is designed to bring haemoglobin up slowly, the recommended rise being 1gm/month.  In other words, he’s going to get decent haemoglobin in about 2-3 months time.  Furthermore, EPO is contraindicated in GI bleeding and his anaemia is probably mainly due to angiodysplasia rather than renal disease.  I would normally commit someone like this to regular transfusion.

2. Oedema – I would try and dry him out and ignore his U&Es.  Our ability to control heart failure is so often hampered by our worrying about the urea rising but I would ignore it.





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