Long Term Complications

Presented by Ms Chua
Haemodialysis Unit
 Topic
1. Anaemia
2. Fluid overload
3. Renal bone disease
4. Cardiovascular disease
5. Infection
6. Others
 Topic
6. Others
•Dialysis Amyloid
•Cancer
•Pruritis
•Neurological complications
•GIB
• Sexual dysfunction
• Aluminium toxicity
• Quality of life
• Rehabilitation
• Special problems to various organ systems
Pathophysiology
 Anaemia
• One of the functions of a kidney is the
production of erythropoietin. A person
diagnosed with ESRD has a reduced
production of erythropoietin.

• Erythropoietin is a hormone produced by the

kidneys to stimulate the bone marrow to
produce red blood cells.
• The kidney is responsible for ~90% of
erythropoietin production

• Anaemia is an early occurring secondary

consequence of progressing renal failure
(develops when creatinine levels reach
2.0mg/dl, even before the onset of dialysis)
• develops depending on the degree of the
severity of the stage of chronic renal
insufficiency

• Serum creatinine concentration is a good

indicator to severity of progression of disease
 Pathogenic Factors of Anaemia
• Decreased endogenous erythropoietin
production

• Impaired erythropoiesis

• Shortened red cell survival

• Chronic blood loss

• Iron or folate deficiency

• Haemolysis

• Gastrointestinal

• Dialysis blood loss

 Anaemia
• There is a strong association
between Hb and risk of death in
ESRD

• Increasing Hb causes major

improvements in quality of life

• Target Hb 11-13g/dl
 Anaemia
• Anaemia is universal in ESRD, primarily due to
relative lack of erythropoietin.
• Decline in renal function is often accompanied
by a decline in haematocrit (HCT) or
haemoglobin (Hb)
• HCT <30% patients may experience malaise,
fatigue, aggravated angina & decreased
exercise tolerance
 Symptoms of Anaemia
1. Eyes – yellowing
2. Skin – paleness, coldness, yellowing
3. Respiratory – SOB
4. Muscular – weakness
5. Intestinal – changes stool color
6. Central – fatigue, dizziness, fainting
7. Blood vessels – low BP
8. Heart – palpitation, chest pain, angina
Conjunctival pallor
 Anaemia
• Causes:
 Shortened red blood cell survival
Acid base & electrolytes disturbances
Iron deficiency
Active blood loss
Haemolysis
Aluminium overload
Infection
 Anaemia
How does dialysis influence Anaemia?

Incomplete blood return after dialysis, dialyzer

leaks and frequent blood sampling
 Investigation
• FBP
• Iron status
- serum ferritin
-Transferrin saturation (serum iron x 100/TIBC)
• Assessment of occult gastrointestinal blood loss
• Assess for aluminium toxicity (Deferoxamine test)
• Bone marrow examination
 Treatment of Anaemia
• Identify and correct underlying causes

• Assess clinical impact

• Ensure adequate nutrition and adequate

dialysis – minimize blood loss through dialyzer

• Iron supplement – oral, IV

 Treatment of Anaemia
• Iron Supplementation
• Oral: B co, Vit C, iron tablet
• Oral iron should not be taken with food and other
medications particularly phosphate binders

 Intravenous Iron
 Iron dextran
 Iron sucrose
 Treatment of Anaemia
• Blood transfusion - when the patient is
symptomatic and rapid correction is required
– Discouraged because it carries the risk of
transmission of viral infection

 Administration of Epoetion (IV or SC)

 Anaemia
Side effects of Epoetin

•Hypertension
•Access thrombosis
 PRCA(Pure red cell aplasia)
• Refers to a type of anemia affecting the
precursors to red blood cells but not to white
blood cells.
• In PRCA, the bone marrow ceases to produce
red blood cells
• The development of pure red cell aplasia (PRCA)
associated with erythropoiesis-stimulating
agent (ESA) therapy was first recognized in 1997
 PRCA
• Signs and symptoms may include fatigue,
lethargy, and/or abnormal paleness of the skin
(pallor)
 PRCA
• The main goals of treatment for pure red cell
aplasia (PRCA) are to restore the production of
red blood cells, maintain adequate
hemoglobin levels, and treat underlying
disorders that may be causing the condition.
 PRCA
• The initial treatment plan typically includes
blood transfusions for individuals who are
severely anaemic and have cardiorespiratory
failure
Epoetin
 Target Iron
Test Minimum Optimal Maximum
target target level
Serum >100 ng/ml 200-500 >800 ng/ml
ferritin ng/ml
TSAT >20% 30-40% >50%
 Take home message
• Anemia is a significant contributor to mortality
and morbidity in CKD

• ESA and iron supplementation forms the core

of anemia management and has to be
understood in detail
 Case Study

30 years old female presents with symptoms of

anemia. What is your management?
1. Causes
2. Blood loss
3. History
4. Diet
5. family history
6. recent illness
7. Physical exam
8. Investigation –
• Peripheral blood film
• FBC (Hb, TW, Platelets, MCV, MCH)
• B12, Folate, Iron Study, TIBC
• Ferritin (iron storage protein)
• Transferrin saturation (measure of iron
available to bone marrow)
THANK YOU
PRESENTED BY
Ms Chua Mei Kwi