Anemia is best managed using a protocol that guides treatment decisions and provides a consistent therapeutic approach. The anemia management protocol is designed to help patients achieve a stable Hemoglobin (Hb) within the target range of 11 to 12 g/dL.
It is the responsibility of the medical provider to determine cause of anemia and initiate appropriate treatment. This protocol does not replace physician's orders, documentation of care, or the patient's response to care.
Definition of Chronic Renal Insufficiency
- Chronic renal insufficiency is defined by GFR, especially in elderly population.
Stage 1 - GFR > 90
Stage 2 - GFR 60-90
Stage 3 - GFR 30-60
Stage 4 - GFR 15-30
Stage 5 - GFR <15 not HD
Stage 6 - GFR < 15 on HD
Patients presenting with suspected anemia or blood test result suggesting of anemia should consider the following:
- In case of acute and chronic anemia obtain baseline CBC, if hemoglobin is low repeat the CBC with reticulocyte count in 24 hours.
- Review results and if hemoglobin decreased by more than 2 points or Hob < 10:
- Order repeat CBC in 2-7 days along with Fe, TIBC, Ferritin, Erythropoietin Level and BMP, and order stool for occult blood x3.
- Obtain a gastroenterology consult, if appropriate.
- All patients should receive appropriate iron replacement with vitamin C supplements.
- All those not responding to treatment should be considered for further investigation.
- In all patients being investigated for iron deficiency anemia, reasonable evidence of IDA should be documented in the notes by appropriate Hb, MCH and MCV or ferritin values, or there should be an explanation of why iron deficiency is suspected in patients not showing typical blood test results.
Use of Procrit:
- The following FDA indications for use should be followed when ordering Procrit.
- Anemia of CKD
- Anemia related to HIV
- Anemia related to Chemotherapy
- Decrease of blood transfusion need due to upcoming surgery.
- Procrit should not be started unless Hb < 10.
- Procrit should be held if Hb > 11.
- Procrit should not be ordered for anemia associated for bone marrow disease- contraindicated.
- Procrit dose should be calculated based on weight and given 3x/week. Dose adjustments should be made in accordance to blood work results.
- Discussion of side effects associated with the use of Procrit with the patient/family needs to be documented in the medical record.
- The following criteria should be considered prior to ordering Procrit:
- Erythropoietin level< 200 (If erythropoietin level > 200 - Procrit is not indicated)
- Ferritin > 80. If less - consider iron deficiency and give iron supplement first.
- TIBC > 20. If less, Procrit not indicated and treat underlying cause.
- Iron level should be normal to high. If low - consider supplementation. (Don't order more than one dose of 50 mcg of ionized iron, which is usually contained in one standard tablet of Feso4.)
- If Hb < 8.0 - schedule outpatient blood transfusion at local hospital’s outpatient transfusion center, if available.
- Transfer to the hospital ER should be considered for the following:
- Active bleeding and/or hemodynamically unstable.
- Patient cannot sit in reclining chair or requires more than 1- person assistance to transfer to reclining chair.
- A CBC should be repeated within 24-72h after blood transfusion.
The Medical Director shall be responsible to ensure compliance to this policy.