Case management of the anemic patient. Epoetin alfa: focus on self-administration

As of July 1, 1991, HCFA will reimburse for Epoetin alfa self-administered by home-based dialysis patients. Implications of this change, including the impact on patients and the changes that will be required to assure effective nursing assessment and optimal patient management, are reviewed.     

Case management of the anemic patient. Epoetin alfa: focus on patient teaching

Nephrology nurses who are highly involved in the care of dialysis patients receiving Epoetin alfa are frequently responsible for educating and monitoring them as well. The following case study shows one methodology that can be used to accomplish these goals. The article highlights topics and terms for patient teaching, and an interdisciplinary care plan for monitoring Epoetin alfa treatments.     

Case management of the anemic patient. Epoetin alfa: focus on nutrition management

As the use of Epoetin alfa to treat the anemia of chronic renal failure expands, attention is beginning to focus on the dietary changes that may occur subsequent to therapy. The anemia-related pattern of poor appetite, lethargy, and decreased mental and physical status can often be reversed as anemia is corrected. Changes in nutritional status increase the importance of monitoring serum chemistries and providing timely interventions. Potentially serious side effects associated with changes in serum chemistries can be minimized or prevented by a teamwork approach involving the physician, nurse, and renal dietitian.     

Case management of the anemic patient. Epoetin alfa: focus on iron management

Stimulation of erythropoiesis by Epoetin alfa causes an increased demand for iron to facilitate hemoglobin synthesis. This article outlines how nephrology nurses can monitor and manage iron levels during Epoetin alfa therapy; including both iron-deficient and iron overloaded patients.     

Case management of the anemic patient. Epoetin alfa: focus on kinetic dosing

Epoetin alfa (EPOGEN, recombinant human erythropoietin) has proven to be a major therapeutic advance in treating the chronic refractory anemia associated with end-stage renal disease (ESRD). As with many medications, the dose of Epoetin alfa must be individualized for each patient. In order to elicit a consistent production of red cells from the bone marrow, it is desirable that dose modifications be made as infrequently as possible. Gotch and Uehlinger have developed a kinetic model that can limit dose modifications by predicting the optimal dose of Epoetin alfa for each patient. Termed the Erythrokinetic Model, it compares individual patient response to Epoetin alfa to the life cycle of a red blood cell. This article describes the Gotch/Uehlinger Erythrokinetic Model and uses it to gauge the clinical response of 2 patients to Epoetin alfa.     

Case management of the anemic patient. Epoetin alfa: focus on oral iron supplementation

Iron is an essential component of Epoetin alfa-supported erythropoiesis, and virtually all patients receiving this medication will eventually require iron supplementation. The use of oral iron supplements is described, and patient assessment, education, and management are emphasized.     

Case management of the anemic patient. Epoetin alfa: focus on inflammation and infection

Nursing management of anemic dialysis patients requires a thorough understanding of the conditions that can potentially affect erythropoiesis. Erythropoietin deficiency has been documented as the primary cause of the anemia of uremia, and Epoetin alfa has proven to be an effective therapy for correcting this condition. However, other etiologies, independent of the uremic process, can also contribute to anemia in these patients and lead to a diminished response to Epoetin alfa. Iron deficiency and blood loss, for example, are well-documented etiologies that can hinder erythropoiesis and diminish the response to Epoetin alfa (Van Wyck, 1989). Another etiology still under investigation is the potential effect of infection or inflammation on the response to Epoetin alfa. This article examines the anemia of infection and inflammation and the potential effect on response to Epoetin alfa.     

Case management of the anemic patient epoetin alfa: focus on aluminum management

Aluminum overload can have a detrimental effect on erythropoiesis which, in turn, can blunt the effectiveness of Epoetin alfa. Nurses can be influential in monitoring, assessing, and preventing aluminum overload.     

Categorizing the response to Epoetin alfa therapy. Case study of the anemic patient

Hyporesponse to Epoetin alfa therapy can be minimized by categorizing patients on the basis of trends in hemoglobin/hematocrit levels and initiating a continuous quality improvement effort that focuses on subnormal outcomes. An algorithm is provided that clinicians can use to proactively assess common causes that contribute to hyporesponse and limit the effect on patient outcomes.     

Epoetin alfa: patient management issues and development through recombinant DNA technology. Part 1: Focus on Epoetin alfa patient management and recombinant DNA technology

The emergence of the Epoetin alfa as an effective therapy in the treatment of the anemia of chronic renal failure has reemphasized the importance of nursing monitoring and intervention in the treatment of these patients. This article examines the role of nurses in monitoring and managing patients receiving Epoetin alfa and the development of medications, such as Epoetin alfa, with recombinant DNA technology.     

Assessing hyporesponse to Epoetin alfa: an algorithm approach: case study of the anemic patient.

Nephrology nurses who manage the anemia of end-stage renal disease (ESRD) are often responsible for monitoring, assessing, and intervening to maintain hemoglobin (Hb) and hematocrit (Hct) levels within their facility target range. Consistency in anemia-related outcomes is sometimes compromised when patients exhibit hyporesponse to Epoetin alfa therapy-defined as a temporary or chronic Hb/Hct level below the target range. Early detection of hyporesponse and correction of conditions that are affecting erythrocyte development can sometimes be delayed if clinicians are unable to promptly identify a causative etiology. This article reviews a hyporesponse algorithm worksheet that nurses can use to identify the cause(s) of hyporesponse and guide clinical decision making.     

Case management of the anemic patient. Focus on hemodynamics

Cardiac function of dialysis patients improves when severe anemia is corrected with Epoetin alfa. Direct clinical changes include a decrease in cardiothoracic ratio and diminished left ventricular size. Exercise-induced cardiac ischemia as noted by depression of the S-T segment on EKG is also reduced. Nephrology nurses must monitor hemodynamic changes, provide patient reeducation, and encourage patient compliance with medication regimens.     

Case management of the anemic patient. Focus on blood pressure and rHuEPO therapy

As the use of Epoetin alfa to treat the anemia of chronic renal failure (CRF) expands, nurses play an ever-increasing role in patient monitoring and control. One area that relies heavily on nurses is blood pressure monitoring. Clinical trials with Epoetin alfa in hemodialysis patients indicate that its use may be associated with the onset or aggravation of elevated blood pressure as the hematocrit level increases. Because high blood pressure is a risk factor for left ventricular hypertrophy and cardiovascular mortality in this patient population, use of an agent that may cause high blood pressure requires careful monitoring. As the following two cases reports illustrate, sufficient data to provide better insight into the clinical aspects of this potential problem have now been accumulated.     

Anemia management in pediatric dialysis patients. Case study of the anemic patient

Anemia is equally devastating in children as in adults. Decreased energy levels from anemia can lead to deterioration in the ability to (a) exercise, (b) participate in the normal activities of childhood, and (c) learn. Moreover, these effects may make it difficult for children to engage in social interactions with their peers, thereby altering their development. Epoetin alfa therapy effectively ameliorates the anemia of end-stage renal disease in pediatric dialysis patients and thus minimizes many of these negative effects. This article examines the use of Epoetin alfa in the pediatric population, including the role of nurses in educating patients and ensuring prescribed outcomes.     

Epoetin alfa in cancer patients: evidence-based guidelines.

Anemia is a common cause of cancer-related fatigue. A systematic review of the literature was performed to establish guidelines on the use of epoetin alfa for the treatment of anemia. The evidence in support of these guidelines was selected, reviewed, and summarized by the members of the Canadian Cancer and Anemia Guidelines Development Group. The effects of epoetin alfa on quality of life (QOL) in patients with cancer were examined in 5 randomized, placebo-controlled trials and 2 large, open-label, nonrandomized, community-based studies. The effects of epoetin alfa on red blood cell transfusion requirements were examined in 19 randomized controlled trials (RCTs) with 21 comparisons. All trials compared epoetin alfa to a suitable control group, examined specified outcome measures that could be analyzed, and studied patients with cancer who were receiving chemotherapy. Trials involving patients with hematologic malignancies originating in the bone marrow were excluded. Outcome measures included 1) quality of life (QOL) (as measured by scales including the Linear Analogue Self-Assessment [LASA] and the Functional Assessment of Cancer Therapy [FACT] subscales), and 2) transfusion requirements (as measured by the proportion of patients requiring transfusion and amount of transfusion). The analysis confirmed that epoetin alfa produced statistically significant and clinically relevant improvements in QOL in patients with cancer. The overall relative risk ratio for transfusion among patients receiving epoetin alfa was calculated to be 0.60 (95% Cl, 0.53-0.69; P < 0.00001), representing a 40% reduction in the proportion of patients requiring transfusion. These results support recommendations for the use of epoetin alfa in patients with cancer-related anemia.     

Epoetin alfa increases hemoglobin levels and improves quality of life in anemic geriatric cancer patients receiving chemotherapy

Goal To evaluate epoetin alfa (EPO) treatment of anemia in geriatric cancer patients receiving chemotherapy, a retrospective subgroup analysis was conducted of anemic cancer patients ≥65 years of age from three 16-week community-based studies of thrice-weekly (TIW) or once-weekly (QW) EPO for chemotherapy-related anemia (CRA).Patients and methods Analyses were conducted on the overall geriatric population (≥65 years) and by age subgroup (65–74, 75–84, and ≥85 years), and compared with younger patients (<65 years) for each individual study and for pooled data.Main results Some 3,634 geriatric patients were compared with 3,467 younger patients. From baseline to final measurement, EPO therapy significantly increased Hb by 2.0 g/dl in patients ≥65 years and 1.9 g/dl in patients <65 years (P<0.0001) and reduced transfusion utilization in both groups (P<0.006). Both age groups also had significant improvements in quality of life (QOL), measured by the 100-mm Linear Analog Assessment Scale (LASA). In younger patients, mean LASA changes were significantly greater than those in geriatric patients (P<0.05); however, QOL improvements in both age groups were clinically meaningful. There were no significant differences across geriatric age subgroups or between TIW and QW regimens for Hb change or QOL improvement. Overall hematopoietic response rate to EPO was 65.4% for patients ≥65 years and 64.7% for patients <65 years. Predictors of greater hematopoietic response (based on a pooled analysis) included lower body weight, baseline Hb, and baseline serum erythropoietin levels; better tumor response; and history of EPO dose reduction and longer time on study.Conclusions Anemic geriatric patients receiving EPO for CRA responded comparably to younger patients <65 years and should be treated similarly.     

Supporting epoetin alfa stimulated erythropoiesis: identifying appropriate iron levels: case study of the anemic patient.

Stimulation of red blood cell precursors by Epoetin alfa results in a predictable, dose-dependent increase in red blood cell mass. Iron is an important substrate that supports red blood cell and hemoglobin development. Patients who receive Epoetin alfa therapy typically require intravenous iron supplementation to ensure proper red cell formation. Target and ceiling iron levels should be determined on the basis of safety considerations, the predicted clinical response, and individual patient replacement needs. Nurses can use clinical parameters such as body weight, baseline and target hemoglobin values, and iron losses from blood and other sources to estimate iron replacement doses, thereby providing a guide for appropriate iron replacement.