Do we have any anemia management experts around here- I have a problem to solve? My iron sat was nice and high as I had had a 5 dose iron load a few weeks prior. Iron sat was 67 the first month and was still high at 60 the next month. Based on these numbers my nurse did not give me a maintenance dose the 2nd month. My hgb was in the 9’s so I was put on 10,000epo, then 15,000 the next month ( I had been totally off epo for 2 months up until this point) as it still had not come up sufficiently. My hgb came up into the 10’s at that point. But I just got labs again and my hgb was back in the low 9’s and my iron sat fell in the toilet at 14!!! When my iron sat was 60 the 2nd month, should that # have been suspect with labs redrawn? I understand that it is possible to get false positives, but how do you gage when iron is needed so that there is not a crash? My nurse went strictly by our protocol, but now I need a 10 dose iron load : (
Hi Jane,
I emailed some RN anemia management experts, and here is what I learned: You need to know what your ferritin level is, and be dosed by BOTH ferritin and Tsat. The Tsat should be redrawn to check for lab error. You should not have been taken off Epo; now you are on the roller coaster. You might have an active infection (thus the low Tsat), but it doesn’t normally drop that rapidly. If you have an infection, iron is contraindicated. So the first step would be to redraw TSat, ferritin and hemoglobin, and go from there.
It sounds suspicious - if you receive 500mg of iron and go up to 67, you probably didn’t need the iron to begin with. I believe that Amgen has a lot of anemia management tools that are free to dialysis nurses, so if yours doesn’t know how to do this correctly, she could ask her Amgen rep…
[QUOTE=Dori Schatell;16534]Hi Jane,
I emailed some RN anemia management experts, and here is what I learned: You need to know what your ferritin level is, and be dosed by BOTH ferritin and Tsat. The Tsat should be redrawn to check for lab error. You should not have been taken off Epo; now you are on the roller coaster. You might have an active infection (thus the low Tsat), but it doesn’t normally drop that rapidly. If you have an
infection, iron is contraindicated. So the first step would be to redraw TSat, ferritin and hemoglobin, and go from there.
It sounds suspicious - if you receive 500mg of iron and go up to 67, you probably didn’t need the iron to begin with. I believe that Amgen has a lot of anemia management tools that are free to dialysis nurses, so if yours doesn’t know how to do this correctly, she could ask her Amgen rep…[/QUOTE]
Dori thanks so much for obtaining this info for me. Do they mean epo should never be totally cut, but just cut back and given as a smaller maintenance dose?
Why is giving 500mg iron and going up to 67 suspicious? My iron sat had dropped to around 17-19 at the time, so I was given the 5 dose iron load. My ferritin was between 600-800 at the time.
How does one know if there is an infection? I have felt well.
My nurse is now looking at hgb weekly and think you are saying iron results come from the same tube. So, it makes sense to me that both need to be checked weekly so she can better gage what my true #'s are and avoid crashes. Maybe the tricky part is that it takes weeks for true epo and iron results to show up. In the meantime, there are false positives.
My nurse has already taken the Amgen training, but apparently she may be missing something, because it doesn’t seem good to me to take iron loads so often. Am I right about that?
Another thing is, how can epo not be cut when hgb climbs too high as Medicare will then not pay for it?
My mistake on the question I asked about hgb and iron results coming from the same tube. I checked on this and 2 different tubes are involved. Found it is possible to check hgb each week, but iron is not tested weekly at my clinic as it can take a whole month for iron results to show up.Don’t know why we weren’t testing hgb weekly previously, because I know it was tested either weekly or twice a month in-center.
Hi Jane,
If your Hgb gets too high, the EPO dose can be reduced–it just shouldn’t be stopped. I believe that your iron level going up so quickly was suspicious–it just doesn’t usually happen that fast, so the result should have been rechecked.
[QUOTE=Dori Schatell;16559]Hi Jane,
If your Hgb gets too high, the EPO dose can be reduced–it just shouldn’t be stopped. I believe that your iron level going up so quickly was suspicious–it just doesn’t usually happen that fast, so the result should have been rechecked.[/QUOTE]
My nurse said it is the protocol for our clinic to cut EPO when Hgb gets too high. She said it depends on the clinic- some cut and some cut back.
Re iron, how long after getting an iron load do you think it should take to show up on labs? My nurse said if the labs are taken too soon after an iron load it will show up as a high false positive. She said it takes about 4 weeks for iron to assimilate in the body in order to get an accurate result which is why they don’t do iron labs more often.
So, to keep on top of things, she will test Hgb weekly. Now what I have to ask her is, if Hgb drops below range, how will she know where my iron is if they only test iron 1x a month. Because if I am given a higher dose of EPO without iron, won’t the EPO eat up whatever iron is there?
This seems a confusing subject, but for me, personally, it’s only confusing because it has never been throughly explained to me and I know of no text for patients that explains it clearly.
Another question I am looking for an answer to is how often one should need an iron load? Is it dependent on how well iron/EPO is managed or is it based on other factors? My nurse said that when one has been on dialysis for years and loses more function, it may be necessary to get iron loads more often.
Hi Jane,
I don’t know all of these answers right now–but I’ll find out, and we’ll do a Topic of the Month article on this! 
That would be great, thanks so much!