EXCERPTA MEDICA
Office of Continuing Medical Education
Self-study Program including materials from an approved satellite symposium of the 33^rd Annual American Society of Nephrology entitled "Evidence-Based Treatment Directives: Correction of Anemia in Early Renal Insufficiency"

POST-TEST ANSWERS

The questions can be found this link

ANSWERS
1.d.
According to data from the United States Renal Data System of the Health Care Financing Administration (HCFA), the care of patients with ESRD has consistently improved over the past 10 years. In 1998, after 6 months of erythropoietin therapy, average hematocrit levels in incident patients increased to nearly 34, approaching the midpoint of the target range of 33 to 36. Data show that as hematocrit levels rise, mortality rates, hospitalizations, and costs tend to decrease, with the greatest benefit seen in patients with hematocrit levels between 33 and 39. When hematocrit levels are <30, a dramatic increase is seen in these outcomes. Controlling costs is becoming increasingly important; it is anticipated that by 2010 the almost 1.5% of Medicare patients with ESRD will consume almost 7% of the Medicare budget.
 
2. b. False.
Although the rise in hematocrit levels is more dramatic in ESRD patients who were treated with erythropoietin before the initiation of dialysis, a rise is also seen in patients who were not treated with erythropoietin. The difference in hematocrit levels between the 2 groups is significant, however.
 
3. a.
At the initiation of dialysis, patients aged ³ 65 years have higher hematocrit levels than do their younger counterparts. The youngest patients have the lowest hematocrit levels. This trend is seen irrespective of erythropoietin treatment; almost 75% of patients never receive erythropoietin. Important trends in anemia are also seen in gender, race, and renal diagnosis patterns among patients in whom dialysis is initiated. Black patients have consistently lower hematocrit levels than do white or Asian populations, and women have lower levels than do men.
 
4. b.
With increases in serum creatinine ³ 1.5 mg/dL and decreases in creatinine clearance <70 mL/min, renal insufficiency increases by degrees. It is likely that the primary care physician would not be concerned by the serum creatinine levels of the vast majority of patients who actually have ERI. ERI is common in the US population, especially among older patients, and carries an increased burden of comorbidity and cardiovascular disease (CVD) risk factors. That many of these individuals are not being referred to a nephrology practice is cause for concern.
 
5. b.
An analysis of data from the third National Health and Nutrition Examination Survey (NHANES III) showed that ~20% of patients with moderate renal impairment have hemoglobin levels of £ 12 g/dL. As renal function decreases from normal to moderately impaired, the risk of anemia increases. Patients with moderately impaired renal impairment have a 2-fold increase in mild anemia and a 2.5-fold increase in severe anemia as compared with persons with normal renal function. Although anemia occurs frequently in ERI, it remains to be explained why most individuals with ERI are not anemic and what the risk factors for anemia in ERI are.
 
6. b. False.
Participants in NHANES III were asked to rate their health—a measure of quality of life—on a scale of 1 to 5, with 1 being excellent and 5 being poor. Patients with moderate renal impairment and hemoglobin levels >12 g/dL reported a mean quality of life score of 3.3, whereas patients with moderate renal impairment and hemoglobin levels <10 g/dL reported mean scores of 3.9. In fact, the effects of renal impairment and anemia are additive, and persons affected by both disorders may suffer a weakened sense of well-being.
 
7. a.
Data in rats demonstrate that systemically administered erythropoietin crosses the blood-brain barrier and interacts with receptors to induce a gene expression program that inhibits cytokine production, thus protecting against a variety of neurologic injuries, including focal ischemia, blunt trauma, excitotoxins, and experimental allergic encephalitis (a model for multiple sclerosis). These animal data for neurologic injury offer the possibility that erythropoietin may be an effective treatment for stroke, trauma, epilepsy, cognitive dysfunction, and a number of neurodegenerative diseases.
 
8. c.
According to data from the 1993/1994 Canadian Dialysis Cohort (Barret et al. Am J Kidney Dis. 1997;29(2):214-222), about 16% of patients starting dialysis had less severe or severe peripheral vascular disease. Among those with severe disease, this comorbidity carries a relative risk of early death of 4.7.
 
9. b. False.
According to data from the Cardiac Disease in Dialysis Patients Study (Parfrey PS, et al. Nephrol Dial Transplant. 1996;11:1277-85.), echocardiography was normal in about 16% of patients starting dialysis. Of 433 enrolled patients receiving baseline echocardiography, 42.1% had concentric LVH, 23.0% had eccentric LVH, and 15.8% had systolic dysfunction. Only 15.6% of these patients had normal echocardiograms. An abnormality on baseline echocardiography was strongly associated with an adverse outcome in these patients.
 
10. a.
Because of the high prevalence of both coronary artery disease and LVH—precursors of morbidity and mortality associated with CVD—in patients with chronic renal disease, this population should be considered at the highest risk for subsequent CVD events and should be treated accordingly. In addition, these patients are further compromised by a high prevalence of congestive heart failure, which is an independent risk factor for death in chronic renal disease.
 
11. a. True.
In a randomized controlled trial by Besarab et al (N Engl J Med. 1998;339(9):584–590), it was projected that hemodialysis patients with symptomatic heart disease (congestive cardiac failure or ischemic heart disease) who were treated with epoetin to normalize hematocrit levels would realize a 30% improvement in mortality outcome. Instead, these patients demonstrated a 30% increase in mortality outcome, suggesting that increasing hematocrit levels to normal may actually be harmful in patients with renal failure and preexisting cardiac conditions.
 
12. c.
A study by Jones et al (Am J Kidney Dis. 1998;32:992) found that 171 white patients and 512 black patients, per million, had hypertension and diabetes. These data show that in a targeted intervention to reduce the incidence, morbidity, mortality, and costs of chronic kidney disease, the black community should be of vital concern. Renal insufficiency also disproportionately affects the poor, when analyzed by both income and insurance factors.
 
13. d.
In a study of 1500 patients with chronic renal insufficiency who went on to develop ESRD, Avorn and Owen et al [Ann Intern Med, in review], found that after adjusting for comorbidity, progression of renal disease, and processes of care, those patients who saw a nephrologist for the first time within the first 90 days after starting dialysis had a 33% increased risk of death at 1 year as compared with patients who were referred earlier. The same study showed that 56% of patients were referred late and 43% were referred early.
 
14. b.
In the clinical management of ERI, the cornerstone of treatment is to be active. The critical components of care for these patients include: blood pressure, epoetin alfa, angioaccess, cardiovascular disease, team approach, iron, vitamin D, and eating well and exercise.