Confusing reply about anemia from Nephrologist. Can someone confirm or dispel.

[chuckt67]

Here's the email, what do you think?

   
To:
xxxxxxxxxx
From:
xxxxxxxx, MD
Received:
4/4/2013  8:56 AM PDT
Not sure if I understand your question, but I will try to explain. The lab results show anemia, ie a low hemoglobin and hemotocrit because they are low. This is due to deficiency in erythropoietin production due to kidney failure. We give supplemental Erythropoetin on dialysis, but we do not aim to normalize the hemoglobin, hence the values you see are below normal.
I hope that helps.


----- Message -----
From: xxxxxxxxx
Sent: 4/3/2013 11:53 AM PDT
To: xxxxxxx, MD
Subject: Anemia

Dr. xxxxxx
At our last meeting, you went over Mom's Labs and stated her anemia is still good. I've pasted the results from the anemia section of the Lab printouts i've been getting since July. It list the following three tests (occasionally omitting one or two). According to my printouts, she has rarely hit the normal ranges. July and Nov are the only dates she hasn't posted Low values here. She has consistently posted normal WBC, low RBC and MCHC, and high MCV and MCH. It's not out of the question that i'm misleading myself, but if i am, they need to change the the way these reports post. I would be happy to fax whatever i have. I apologize if this email doesn't keep my formatting below.

                           Range________7/5__7/10    7/17  7/24  8/14  8/21    9/4    10/2 11/6  12/4    12/7   1/3    1/8      2/5     3/5
HEMATOCRIT____%37.0 - 47.0__40.4____x______ x        x       x    33.9L  36.1L  40.4  40.0  35.8L     x       x     30.8L   30.4L  35.9L
CT CALC(HGBX3)_%37.0 - 47.0__36.0L__32.4L__ 32.1L    x          x    30.3L  32.4L  38.1  37.8  32.7L  32.1L 30.9L  29.4L  29.4L  33.0L
HEMOGLOBIN__G/DL12.0 - 16.0__12.0__10.8L___10.7L  10.5L 9.9L  10.1L  10.8L  12.7  12.6  10.9L  10.7L 10.3L  9.8L    9.8L    11.0L



   

[cattlekid]

Your neph is completely correct.  The "low", "high" etc. on most lab reports are for "normal" people, not those of us on dialysis.  ESRD patients are kept to a hemoglobin range of 10-12.  Anything below 10 is treated usually with EPO and/or IV iron (venofer), and if you go over 12, your EPO is usually held until you come back down.  It sucks for those of us who are young and otherwise healthy, because keeping us at the 10-12 range is like constantly swimming in mud.

[Henry P Snicklesnorter]

.

[jeannea]

Cattlekid is correct. You can't go by the "high" or "low" normally printed by the lab or compare the results to online ranges. The best you can do is educate yourself on what to expect for people with dialysis. Then you'll know if your mother is having a problem.

[chuckt67]

She used to do peritoneal with a different provider. While they became completely incompetent (failed to diagnose a mechanical disorder with PD cath until after the switch to hemo, then botched the graft to the only vein large enough for perm access) causing us to go to Original Medicare, at least their labs results were adjusted for patients with CKD. DaVita draws blood from only dialysis patients and sends it to their own Lab to be analyzed by their own technician, who then sends them back to only be seen by Davita patients. And they can't adjust the ranges for us

[amanda100wilson]

everyone else is correct.  Whilst the nephrologist appears to have appalling grammar skills, he is right.  The values whilst low in comparison to those given in the range are above the threshold for epo. injections.   were your mum's levels to fall below 10, then these injections would be started.  a lot of us here would love to have values that ranged as high as your mum's.  The way that these values read is standard practice.  however, it would be helpful if the doctor  had explained this to you. 

[JasonEb]

Just thought I'd add a bit to this...

It is possible to get your neph to order a special regimen of epo if the case warrants it.  I have a problem that when I reach the "magic number" and the protocol takes away my epo, my Hgb drops like a stone.  For a dozen years I have gone through the same rollercoaster of struggling to get my Hgb to 11 just for them to cut it out then plummeting down to low levels (6-8) before they realize it and restarting epo infusion and begin the long, slow climb back up to feeling like I'm not swimming uphill through quicksand.  A few helpful nurses over the years have tried to fix this by having my neph order to not cancel my epo when I reach 11, merely lower the dose to "maintain".  Yet inevitably that order falls back in the pages of my binder and the nurse moves on to somewhere else and once again "BAM!", epo cut off and quickly plummets before the problem is caught.

The latest attempt by the current charge nurse is that not only did she have my neph write the order to not cut off my epo until I reach 12.5, then lower dose (though I have yet to get above 11.1 and tend to hover in the low 10's due to the amount of epo they give me), but she also has it as a permanent note on my treatment sheets.  So if she leaves, it will still be there.  Time will tell if it sticks this time, but at least she tried.

Anyway, as stated, if you can prove a reason for more epo and depending on whether your (mom's) doctor is willing, they can increase the dosage/order.

[Grumpy-1]

I'm like JasonEb  (and age doesn't have anything to do with it)  I'm 61 and if my level drops below 10 I crash.  When I was on PD, the nurses keep a close eye on it and if it was dropping they would contact the Dr and increase or restart the EPO.  I was in "maintenance mode".  I'm now on hemo and they don't monitor it as well.  Last month it dropped to 8.2 and no matter what I said or how bad I felt, no one did anything.  It took a month before the Dr noticed it and started EPO and Iron.  Like JasonEb, it a long climb back up to MY NORMAL.  Wish the Dr would listen and let me keep it at 11 or 12.  BUT according to the FDA, anything above 10 is a risk.  Never mind that professional athletes can have a level or 17 or 18.  OH well. 

ChuckT67 keep monitoring your mum's level and stay on the Dr until SHE is feeling better - never mind the numbers alone. It is how she feels that is important.

Grumpy

[Cowdog]

Everyboby's situation and body is different. When I 1st started hemo my hemoglobin was at the 9-10 range and I was given epo and iron. PTH went crazy in 2010 up to 1100 and I had my parathyroids removed Dec of that year. After recovering from the surgery my hemoglobin went up and has stayed in the 13 - low 14 range with no Epo or Iron. Tested Tuesday this week at 14.1. Actually causes a problem with labs because the samples tend to clot so quick. Staff declared there to be something wrong with me in 2011 and sent me to a hemotologist for blood evaluation for cancer or leukemia also had imaging to check for kidney cysts. All test came back clear and he said I was just on the low end of normal for the general population and extremely high for an ESRD patient. Once again a Dr using the term idopathic in his explanitation. Seems everything thing I have turns out to be idopathic.
For me 13-14 feels sooo much better than 9-10.

[BattleScars]

Mine was 8.9 after my last labs. What I would do for that result! I feel lousy most of the time. I need to start my shots again.