Summertime lethargy may be due to anemiaby Michael BakerPublic Relations As July settles on South Carolina, Charleston swelters in the midsummer heat. For people with chronic kidney disease, the dreamy languor of summertime may not be a product of the season. Rather, their lethargy may be a symptom of anemia. Now an interdisciplinary team at MUSC can make that determination. Since February 2003, the Anemia Clinic in the Division of Nephrology served patients with anemia related to chronic kidney disease. According to clinic medical director Rachel Sturdivant, M.D., anemia has become an increasing risk for many South Carolinians. “In this state, one person out of eight suffers from chronic kidney disease,” she said. “That means 460,000 people are at risk of developing anemia, if they haven’t already.” So what is anemia? Anemia indicates a lack of red blood cells, which contain a protein called hemoglobin. Transported within red blood cells, hemoglobin carries oxygen to various parts of the body, allowing organs and tissue to function properly. Patients with anemia, however, do not experience the level of oxygen circulation that a healthy person does. “Anemia can cause a number of health problems,” Sturdivant explained. “Besides tiring easily and experiencing shortness of breath, anemia patients often feel cold, experience sexual dysfunction, and lose a general sense of well-being.” Less apparent effects of anemia include cognitive dysfunction and a higher risk of left ventricular hypertrophy, or a thickened heart. Although many health conditions cause anemia, the clinic focuses on anemia associated with chronic kidney disease. Nurse practitioner Deborah Brooks, R.N., works with pre-dialysis anemia patients, employing treatment and education to help them understand their condition. “The most interesting thing about working in the clinic is the misconception that many patients have about the kidneys,” she said. “They think the kidneys only make urine, and they don’t realize the range of responsibilities that the organs actually have.” The kidneys produce a hormone called erythropoietin, which signals bone marrow to make red blood cells. Diseased kidneys either don’t produce the hormone or don’t produce enough, leaving the bone marrow idle and underproductive. With a limited amount of red blood cells being produced, a person becomes anemic. “As I explain it to our patients, bone marrow is like a factory waiting for an order to come in,” Brooks said. “The marrow may be ready to produce more red blood cells, but if it doesn’t get the signal from the hormone, it can’t do its job.” Part of the Anemia Clinic’s treatment program involves erythropoietin analog injections, which introduce the hormone into the body through an injection under the skin. “The bone marrow doesn’t care where it’s getting the hormone from, so erythropoietin injections provide a competent substitute for underproductive kidneys,” Brooks said. “We inject the hormone, it sends signals to the bone marrow, and the marrow produces red blood cells.” The injections work for some patients, but the presence of erythropoietin solves only half of the problem. A lack of iron in the bone marrow also may cause anemia. “Iron is a key component in making red blood cells,” Sturdivant explained. “In that sense, it doesn’t matter how much erythropoietin you have. The hormone can send production signals all day, but without iron, the bone marrow can’t make red blood cells.” According to Sturdivant and Lynn Uber, Pharm.D., clinical specialist, many patients with chronic kidney disease have iron deficiencies due to poor absorption, diets lacking in iron, or numerous blood draws. For this reason, the clinic uses oral or intravenous iron supplements to combat anemia. By treating both issues—decreased erythropoietin hormone production and iron deficiency—the clinic improves the physical and mental health of its patients. They often recover from their physical ailments and find that their moods and overall attitude have improved. The elimination of symptoms like fatigue, shortness of breath, and muscle pain leaves many patients feeling healthy and more capable; thus, their spirits improve. Equally important to the clinic’s success is its ability to provide fast, efficient care to patients with anemia. “We have a very good interdisciplinary system—a medical director, a nurse practitioner, a clinical pharmacist, and clinic nurses all working together,” Uber said. Together they write clinic protocols, educate patients, and manage the treatment of anemia. In some cases, they also help uninsured patients receive therapy through the Pharmacy Medication Assistance Program. “Each drug company has specific criteria within their patient assistance programs,” she said. “If a patient meets the financial requirements, the company will provide the drug for free. We take this into consideration with any patient who has trouble making payments.” Sturdivant added that the clinic is trying to implement a program that would facilitate Medicaid patients paying for the medication with their prescription cards as well. Amidst providing anemia patients with treatment options, preventative education, and financial assistance, the clinic’s efforts haven’t gone unnoticed. Its existence relieves a common dilemma of MUSC nephrologists. A typical office visit couldn’t focus adequately on the specific problems of anemic patients. “If a typical visit lasts 30 minutes and a patient has 12 or 13 issues to address, the nephrologist doesn’t have time to focus solely on anemia,” Uber said. “Not every patient with chronic kidney disease has anemia, but those that do can get specialized care at the clinic. “Once the nephrologist identifies anemia in a patient with chronic kidney disease,” Sturd-ivant said, “the Anemia Clinic can assume primary responsibility for the frequent laboratory monitoring and therapeutic drug-dose adjustments required to treat anemia effectively. This allows our nephrologists to focus on the other health issues confronting patients with chronic kidney disease.” So far, she added, the clinic has been more efficient in getting patients to their goal levels of hemoglobin. Before the clinic opened, nephrologists were able to check their patients’ hemoglobin and erythropoietin dosing levels every three months. Now the clinic monitors its patients every month and makes adjustments to their dosages regularly. The increased frequency allows the patients to reach their hemoglobin goals more quickly. Sturdivant places much of the credit on her colleagues’ shoulders. “Deborah and Lynn have been instrumental to the clinic’s success,” she said. “They’re such a big help, making the clinic a nice addition to the Division of Nephrology.” Anemia Clinic, Division of Nephrology
Friday, July 16, 2004
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