NURSING CARE MANAGEMENT :
Anemia Of Chronic Kidney Disease
IMAM HADI YUWONO
CHRONIC KIDNEY DISEASE (CKD)
Kidney disease is classified based on
glomerular filtration rate (GFR), according to
the Kidney Disease Outcomes Quality
Initiative Guidelines of the National Kidney
Foundation. Chronic kidney disease (CKD)
involves kidney damage (by pathology,
imaging, or clinical tests) or GFR < 60
mL/min/1.73 m2 for 3 months or longer. A
GFR of 60 is chosen, as it defines loss of at
least 50% of the normal adult kidney function
[1].
The different stages of CKD form a
continuum. The stages of CKD are classified
as follows:
1. Stage 1: Kidney damage with normal or
increased GFR (>90 mL/min/1.73 m 2)
2. Stage 2: Mild reduction in GFR (60-89
mL/min/1.73 m 2)
3. Stage 3a: Moderate reduction in GFR (45-
59 mL/min/1.73 m 2)
4. Stage 3b: Moderate reduction in GFR
(30-44 mL/min/1.73 m 2)
5. Stage 4: Severe reduction in GFR (15-29
mL/min/1.73 m 2)
6. Stage 5: Kidney failure (GFR <15
mL/min/1.73 m 2 or dialysis)
In stage 1 and stage 2 CKD, reduced GFR
alone does not clinch the diagnosis, because
the GFR may in fact be normal or borderline
normal. In such cases, the presence of one or
more of the following markers of kidney
damage can establish the diagnosis. [1]
BIDANG PENELITIAN DAN PENGABDIAN MASYARAKAT PP. IPDI
1. Albuminuria (albumin excretion >30
mg/24 hr or albumin:creatinine ratio >30
mg/g [>3 mg/mmol])
2. Urine sediment abnormalities
3. Electrolyte and other abnormalities due to
tubular disorders
4. Histologic abnormalities
5. Structural abnormalities detected by
imaging
6. History of kidney transplantation in such
cases
Hypertension is a frequent sign of CKD but
should not by itself be considered a marker of
it, because elevated blood pressure is also
common among people without CKD. In an
update of its CKD classification system, the
NKF advised that GFR and albuminuria levels
be used together, rather than separately, to
improve prognostic accuracy in the assessment
of CKD. [3,4] More specifically, the
guidelines recommended the inclusion of
estimated GFR and albuminuria levels when
evaluating risks for overall mortality,
cardiovascular disease, end-stage kidney
failure, acute kidney injury, and the
progression of CKD. Referral to a kidney
specialist was recommended for patients with
a very low GFR (<15 mL/min/1.73 m²) or very
high albuminuria (>300 mg/24 h). [1,2]
Signs and symptoms
Patients with CKD stages 1-3 are generally
asymptomatic. Typically, it is not until stages
4-5 (GFR <30 mL/min/1.73 m²) that
endocrine/metabolic derangements or
disturbances in water or electrolyte balance
become clinically manifest.
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Signs of metabolic acidosis in stage 5 CKD
include the following:
1. Protein-energy malnutrition
2. Loss of lean body mass
3. Muscle weakness
Signs of alterations in the way the kidneys are
handling salt and water in stage 5 include the
following:
1. Peripheral edema
2. Pulmonary edema
3. Hypertension
Anemia in CKD is associated with the
following:
1. Fatigue
2. Reduced exercise capacity
3. Impaired cognitive and immune function
4. Reduced quality of life
5. Development of cardiovascular disease
6. New onset of heart failure or the
development of more severe heart failure
7. Increased cardiovascular mortality
Anemia usually is grouped into three etiologic
categories: decreased RBC production,
increased RBC destruction, and blood loss.
Anemia of chronic illness and anemia of
chronic kidney disease (CKD) both fall under
the category of decreased RBC production.
When the classification of anemia is based on
the morphology of the RBCs, both anemia of
chronic illness and chronic kidney disease
usually fall under the classification of
normochromic, normocytic anemia.[5]
You may be familiar with the term "anemia"
because having anemia is common when you
have chronic kidney disease (CKD). Anemia
happens when you do not have enough red
blood cells. In CKD, kidneys don't make
enough of a hormone called erythropoietin
(EPO), which your body needs to make red
blood cells. Your body also needs iron to make
red blood cells. When there is not enough EPO
or iron, you make fewer red blood cells, and
anemia develops. In kidney disease, anemia
BIDANG PENELITIAN DAN PENGABDIAN MASYARAKAT PP. IPDI
can happen even before the kidneys fail, and it
is very common in people on dialysis [6]
In general, anemia is more common in women,
in particular, those in their childbearing years.
In the latter decades of life, anemia tends to
occur without any particular sex predilection.
However, in patients with chronic kidney
disease (CKD), the risk of developing anemia
is 30% higher in males than in females.
Although males have higher hemoglobin
values, they also have higher rates of advanced
CKD. The prevalence of anemia is lower in
current smokers, which has been attributed to
secondary erythrocytosis [8].
NURSING ASSESSMENT
The assessment of anemia involves the
following :
1. Health history and physical exam. Both
provide important data about the type of
anemia involved, the extent and type of
symptoms it produces, and the impact of
those symptoms on the patient’s life.
2. Medication history. Some medications can
depress bone marrow activity, induce
hemolysis, or interfere with folate
metabolism.
3. History of alcohol intake. An accurate
history of alcohol intake including the
amount and duration should be obtained.
4. Family history. Assessment of family
history is important because certain
anemias are inherited.
5. Athletic endeavors. Assess if the patient
has any athletic endeavor because extreme
exercise can decrease erythropoiesis and
erythrocyte survival.
6. Nutritional assessment. Assessing the
nutritional status and habits is important
because it may indicate deficiencies in
essential nutrients such as iron, vitamin
B12, and folic acid [7].
In-Depth Assesment
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Although not everyone has the same
symptoms, anemia can cause to:
1. Have little energy for daily activities
2. Look pale
3. Feel tired or weak
4. Have cold hands and feet
5. Be irritable
6. Have brittle nails
7. Have unusual cravings for odd things like
ice or dirt
8. Have a poor appetite
9. Feel dizzy or have headaches
10. Have trouble sleeping
11. Feel short of breath
12. Have trouble thinking clearly
13. Have a rapid heartbeat
14. Feel depressed or "down in the dumps"
15. Have restless leg syndrome — an
uncomfortable tingling or crawling feeling
in your legs [6].
DIAGNOSIS
Based on the assessment data, major nursing
diagnosis for patients with anemia include:
1. Fatigue related to decreased hemoglobin
and diminished oxygen-carrying capacity
of the blood.
2. Altered nutrition, less than body
requirements, related to inadequate intake
of essential nutrients.
3. Altered tissue perfusion related to
insufficient hemoglobin and hematocrit [7].
PLANNING & GOALS
The major goals for a patient with anemia
include:
1. Decreased fatigue
2. Attainment or maintenance of adequate
nutrition.
3. Maintenance of adequate tissue perfusion.
4. Compliance with prescribed therapy.
BIDANG PENELITIAN DAN PENGABDIAN MASYARAKAT PP. IPDI
5. Absence of complications.
NURSING INTERVENTIONS
Nursing interventions are based on the data
assessed by the nurse and on the symptoms
that the patient manifests [7].
To manage fatigue:
1. Prioritize activities. Assist the patient in
prioritizing activities and establishing
balance between activity and rest that
would be acceptable to the patient.
2. Exercise and physical activity. Patients
with chronic anemia need to maintain some
physical activity and exercise to prevent the
deconditioning that results from inactivity.
To maintain adequate nutrition:
1. Diet. The nurse should encourage a healthy
diet that is packed with essential nutrients.
2. Alcohol intake. The nurse should inform
the patient that alcohol interferes with the
utilization of essential nutrients and should
advise the patient to avoid or limit his or
her intake of alcoholic beverages.
3. Dietary teaching. Sessions should be
individualized and involve the family
members and include cultural aspects
related to food preference and preparation
[7].
To maintain adequate perfusion:
Blood transfusion monitoring. The nurse
should monitor the patient’s vital signs and
pulse oximeter readings closely.
To promote compliance with prescribed
therapy:
1. Enhance compliance. The nurse should
assist the patient to develop ways to
incorporate the therapeutic plan into
everyday activities.
2. Medication intake. Patients receiving high-
dose corticosteroids may need assistance to
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 obtain needed insurance coverage or to
explore alternative ways to obtain these
medications [7]
EVALUATION
Included in the expected patient outcomes are
the following:
1. Reports less fatigue.
2. Attains and maintains adequate nutrition.
3. Maintains adequate perfusion.
4. Absence of complications.
Discharge and Home Care Guidelines
Health education is the main focus during
discharge and for the home care.
1. Instruct the patient to consume iron-rich
foods to help build-up hemoglobin stores.
2. Iron supplements. Enforce strict
compliance in taking iron supplements as
prescribed by the physician.
3. Follow-up. Stress the need for regular
medical and laboratory follow-up to
evaluate disease progression and response
to therapies [7]
Documentation Guidelines
The data to be documented consists the
following:
1. Baseline and subsequent assessment
findings to include signs and symptoms.
2. Individual cultural or religious restrictions
and personal preferences.
3. Plan of care and persons involved.
4. Teaching plan.
5. Client’s responses to teachings,
interventions, and actions performed.
6. Attainment or progress toward desired
outcome.
7. Long-term needs, and who is responsible
for actions to be taken [7]
PATIENT UNDERGOING DIALYIS
BIDANG PENELITIAN DAN PENGABDIAN MASYARAKAT PP. IPDI
Are people on dialysis at risk for not getting
enough iron?
Yes. People on dialysis need extra iron
because of:
1. Lack of iron-rich foods in your diet
Some foods that are rich in iron like red
meats and beans may be limited in your
dialysis diet. Without enough iron-rich
foods, you are more at risk for not getting
enough iron. Your dietitian can help you
choose foods that are good sources of iron,
vitamins and other minerals. Check with
your dietitian before making any changes in
your diet.
2. Blood loss during hemodialysis
At the end of each hemodialysis treatment,
a small amount of blood is usually left
behind in the dialyzer (artificial kidney).
This can be a source of iron loss over time.
In fact, when you are on dialysis, you will
probably need extra iron because you will
be taking another anemia medicine, called
ESA (see below), that uses up your iron.
Your dialysis care team will do blood tests
to find out if you have iron deficiency
anemia and make the right plan of care for
you. They will check your hemoglobin
regularly to watch how well your anemia
treatment is working.
Your dialysis team will also test your
blood iron levels because iron helps your
body make enough hemoglobin. Having
enough iron helps you reach and stay in the
recommended hemoglobin range [6].
How is my iron level tested?
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Two important blood tests can tell if you have
enough iron. They are called transferrin
saturation (TSAT) and ferritin (a form of iron
that is stored in the body's tissues).
1. Your TSAT level should be at least 20
percent.
2. Your ferritin level should be at least 100
ng/mL if you are on peritoneal dialysis, and
more than 200 ng/mL if you are on
hemodialysis.
Your dialysis care team will test your iron
levels regularly until you reach your
hemoglobin target.. After that, they will test
it every 3 months if your hemoglobin is
stable.
How is anemia treated in people on
dialysis?
In people on dialysis, anemia is treated with:
1. Drugs called erythropoiesis stimulating
agents (ESAs). ESAs replace the EPO that
is low in people with kidney failure, so they
can make red blood cells.
2. Extra iron. Diet alone cannot supply
enough iron to meet your needs. You will
most likely need extra iron. . In fact, once
you start taking ESAs, you will make more
red blood cells and your iron supply will be
used up faster. When you take an ESA, iron
therapy helps to:
a. prevent iron deficiency
b. lower the amount of ESA needed
c. keep your hemoglobin within range.
You may wonder if it is possible to end up
with too much iron. The use of ESAs helps
reduce the build-up of iron. Your dialysis
care team will test the iron level in your
blood to make sure your iron level is right
for the type of dialysis you are having. The
amount of iron you need and how you will
receive it depends upon the type of dialysis
you get [6].
BIDANG PENELITIAN DAN PENGABDIAN MASYARAKAT PP. IPDI
3. If you receive peritoneal dialysis, extra iron
can be:
a. Taken orally as a supplement
b. Given IV. (This means "intravenous" or
infusion into a vein.)
4. If you receive hemodialysis, you can get
extra iron as either IV iron, a large iron
dose that is injected through the dialysis
machine, or as a small iron dose that is part
of the dialysis solution
Why is it important to treat anemia?
Anemia can cause serious problems with your
heart. Treating your anemia is important
because:
1. You will have more energy to do your daily
tasks.
2. Your quality of life gets better.
3. Your ability to exercise improves.
4. Your chance of having heart problems is
lower.[6]
Dialysis And CKD
Dialysis is one treat for CKD. Other
manifestations of uremia in end-stage renal
disease (ESRD), many of which are more
likely in patients who are being inadequately
dialyzed, include the following [1] :
1. Pericarditis: Can be complicated by cardiac
tamponade, possibly resulting in death if
unrecognized
2. Encephalopathy: Can progress to coma and
death
3. Peripheral neuropathy, usually
asymptomatic
4. Restless leg syndrome
5. Gastrointestinal symptoms: Anorexia,
nausea, vomiting, diarrhea
6. Skin manifestations: Dry skin, pruritus,
ecchymosis
7. Fatigue, increased somnolence, failure to
thrive
8. Malnutrition
9. Erectile dysfunction, decreased libido,
amenorrhea
10. Platelet dysfunction with tendency to bleed
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SUMMARY
In general, anemia is common in chronic
kidney disease (CKD). Anemia happens when
the body do not have enough red blood cells.
In CKD, kidneys don't make enough of a
hormone called erythropoietin (EPO), which
the body needs to make red blood cells. The
body also needs iron to make red blood cells.
When there is not enough EPO or iron, the
body make fewer red blood cells, and anemia
develops. In kidney disease, anemia can
happen even before the kidneys fail, and it is
very common in people on dialysis. At the end
of each hemodialysis treatment, a small
amount of blood is usually left behind in the
dialyzer (artificial kidney). This can be a
source of iron loss over time.
Nursing intervention for anemia in CKD are
then following manage fatigue, maintain
adequate nutrition, maintain adequate
perfusion and promote compliance with
prescribed therapy.
REFERENCES
1. Kidney Disease: Improving Global
Outcomes (KDIGO) CKD Work Group.
KDIGO clinical practice guideline for the
evaluation and management of chronic
kidney disease. Kidney Int Suppl. 2013;
3:1-150.
2. Waknine Y. Kidney Disease Classification
to Include Albuminuria. Medscape Medical
News. Available at http://www.medscape.
com/viewarticle/776940. December 31,
2012; Accessed: January 2, 2018.
BIDANG PENELITIAN DAN PENGABDIAN MASYARAKAT PP. IPDI
3. Clapp, WL. "Renal Anatomy". In: Zhou
XJ, Laszik Z, Nadasdy T, D'Agati VD,
Silva FG, eds. Silva's Diagnostic Renal
Pathology. New York: Cambridge
University Press; 2009.
4. Le, Tao. First Aid for the USMLE Step 1
2013. New York: McGraw-Hill Medical,
2013. Print.
5. Lerma, E, V. Anemia of Chronic Disease
and Renal Failure. https://emedicine.
medscape.com/article/1389854-
overview#a1 Nov 09, 2017 Accesed :
January 3, 2018
6. National Kidney Foundation (NKF)
Anemia and Iron Needs in Dialysis
https://www.kidney.org/atoz/content/iron
Dialysis March 3, 2017, Accesed : January
4, 2017
7. Belleza, M., Anemia: Nursing Care
Management.
https://nurseslabs.com/anemia Sep 16, 2016
Accesed : January 3, 2018
8. Obrador GT, Ruthazer R, Arora P, Kausz
AT, Pereira BJ. Prevalence of and factors
associated with suboptimal care before
initiation of dialysis in the United States. J
Am Soc Nephrol. 1999 Aug. 10(8):1793-
800.
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