CDN Anemia Management in Dialysis Patients 2 — Questions and Answers
Question 1: What is the most common cause of ESA hyporesponsiveness (failure to achieve target hemoglobin despite adequate ESA doses) in dialysis patients?
- Vitamin B12 deficiency
- Iron deficiency (Correct answer)
- Folate deficiency
- Aluminum toxicity
Correct answer: Iron deficiency
Iron deficiency is by far the most frequent cause of ESA hyporesponsiveness because adequate iron supply is essential for the bone marrow to respond to ESA stimulation and synthesize hemoglobin.
Question 2: Which condition is an absolute contraindication to continued ESA therapy in a dialysis patient?
- Uncontrolled hypertension
- Confirmed pure red cell aplasia (PRCA) due to anti-EPO antibodies (Correct answer)
- Recent myocardial infarction
- Active infection with elevated CRP
Correct answer: Confirmed pure red cell aplasia (PRCA) due to anti-EPO antibodies
Pure red cell aplasia caused by anti-EPO antibodies is an absolute contraindication because continuing ESA therapy will worsen PRCA and could be life-threatening; ESA must be permanently discontinued.
Question 3: How frequently should hemoglobin be monitored in stable hemodialysis patients receiving ESA therapy?
- Weekly
- Monthly (Correct answer)
- Every 3 months
- Every 6 months
Correct answer: Monthly
Monthly hemoglobin monitoring is recommended for stable dialysis patients on ESA therapy to allow timely dose adjustments and detect trends before hemoglobin rises above or falls below target range.
Question 4: According to KDIGO guidelines, above what serum ferritin level should IV iron supplementation generally not be routinely administered due to risk of iron overload?
- 200 ng/mL
- 300 ng/mL
- 500 ng/mL (Correct answer)
- 800 ng/mL
Correct answer: 500 ng/mL
KDIGO 2012 guidelines recommend withholding routine IV iron when ferritin exceeds 500 ng/mL, as higher levels suggest adequate stores and raise concern for iron overload and toxicity.
Question 5: Which vitamin is routinely supplemented alongside ESA therapy in hemodialysis patients to support effective erythropoiesis?
- Vitamin C
- Vitamin D
- Folic acid (Vitamin B9) (Correct answer)
- Vitamin K
Correct answer: Folic acid (Vitamin B9)
Folic acid is water-soluble and dialyzed out during each treatment; adequate folate is essential for DNA synthesis in proliferating red cell precursors, and deficiency impairs the response to ESA therapy.
Question 6: A hemodialysis patient who has been on epoetin alfa for 14 months develops a sudden severe drop in hemoglobin with near-absent reticulocytes. What should the nurse suspect?
- Acute iron deficiency from GI blood loss
- Pure red cell aplasia (PRCA) from anti-EPO antibodies (Correct answer)
- Hemolysis from dialyzer reaction
- Folate deficiency anemia
Correct answer: Pure red cell aplasia (PRCA) from anti-EPO antibodies
The combination of sudden severe anemia with reticulocytopenia after prolonged ESA exposure is the classic presentation of PRCA caused by neutralizing anti-erythropoietin antibodies.
Question 7: Which intravenous iron preparation is most widely used during hemodialysis sessions in the United States due to its established safety profile and ease of administration?
- Ferric gluconate (Ferrlecit)
- Iron sucrose (Venofer) (Correct answer)
- Ferumoxytol (Feraheme)
- Ferric carboxymaltose (Injectafer)
Correct answer: Iron sucrose (Venofer)
Iron sucrose (Venofer) has an excellent safety record, can be administered in small doses over each dialysis session without a test dose, and is one of the most widely used IV iron preparations in US dialysis centers.
CDN Anemia Management in Dialysis Patients 2
What is the most common cause of ESA hyporesponsiveness (failure to achieve target hemoglobin despite adequate ESA doses) in dialysis patients?