Health Tips

If you have a chronic kidney disease (CKD), then you are also very likely to experience anemia. 

Anemia in CKD

Anemia happens when your red blood cells are in short supply. Red blood cells carry oxygen from your lungs to all parts of your body, giving you the energy you need for your daily activities. 

Anemia can cause you to:

• Look pale

• Feel tired

• Low energy level for your daily activities

• Have a poor appetite

• Have trouble sleeping

• Have trouble thinking clearly

• Feel dizzy or have headaches

• Have a rapid heartbeat

• Feel short of breath

• Feel depressed 

Anemia is not only unique to people with CKD. However, why is anemia a common condition across CKD patients? Well, this is because our kidneys do not only filter off wastes and retain nutritions, they also produce a hormone known as erythropoietin (EPO). EPO tells your body to make more red blood cells. When you have kidney disease, your kidneys cannot make enough EPO. As a result, low EPO levels cause your red blood cell count to drop and anemia to develop. 

Image credit to: Shih H, Wu C, Lin S. Physiology and pathophysiology of renal erythropoietin-producing cells. Journal of the Formosan Medical Association. 2018;117(11):955-963.

However, not everyone with anemia develops the symptoms mentioned above. Your doctor diagnoses anemia by taking your blood test to measure your haemoglobin level. Hemoglobin is the part of red blood cells that carries oxygen throughout your body. If your hemoglobin is too low, it is likely you have anemia. In that case, your doctor will plan a treatment that is right for you.

The treatment usually starts with taking iron supplements. However, in some cases, iron supplements may not be adequate to bump up a person’s haemoglobin level. That’s when doctors may consider recommending ESA to you.

What is ESA?

Erythropoiesis stimulating agents (ESAs) are injections that help your body make red blood cells. You can see it as a replacement for the EPO that your body now lacks. There are various types of ESA available in the market, such as:

• Epoetin Beta (Recormon®)

• Epoetin Alfa (Erysaa®, Eprex®)

• Methoxy polyethylene glycol-epoetin beta (Mircera®)

So far there’s no ESA medications that you can take orally. Some of these ESA require you to be present at a health facility to receive injections done by medical personnel. Nonetheless, it’s quite common for patients to carry out Recormon® injections at home by themselves. Clarify with your doctor if you’re allowed to do self-injection at home or come to the health facility for injections.

Once you’re on an ESA therapy, your doctor would test your iron and haemoglobin level regularly until your anemia is well-controlled. It’s also important for you to ensure an adequate intake of iron despite ESA therapy. Without enough iron, ESA is wasted and you will not reach your target hemoglobin. Consult your doctor, pharmacist or nutritionist the best way to ensure your iron intake either through diet or supplements.

Injecting Epoetin Beta (Recormon®) at home

The frequency of injections may vary from person to person, but it typically ranges from once to thrice weekly. In less severe cases, injections can be prescribed monthly. Recormon® is available in various strengths, with the commons one are  2,000IU/0.3ml, 4,000IU/0.3ml and 5,000IU/0.3ml. They come in a form of pre-filled syringe.

Image from MIMS Malaysia

Recormon® is injected subcutaneously, i.e. injected under the skin into fat tissue. Hence, the appropriate site of injections are abdomen, thigh, upper arm or buttock. 

Before injecting Recormon®, you would need:

• Recormon® pre-filled syringe prescribed by your doctor, which should be kept in the refrigerator prior to use

• Alcohol swab

• Hand sanitiser or access to water and soap

• Dry, sterile pad

The general injection technique is as follows:

1. Remove one syringe from the refrigerator and check that the solution is clear, colourless and free from visible particles

2. Allow Recormon® to reach room temperature

3. Clean your hands with hand sanitiser or wash your hands with soap and water.

4. Remove one needle from the pack, fix it on the syringe and remove the protective cap from the needle

5. Expel air from the syringe and needle by holding the syringe vertically and gently pressing the plunger upwards

6. Clean the skin with alcohol wipes before forming a skin fold at the site of injection

7. Form a skin fold by pinching the skin between thumb and forefinger

8. Insert the needle into the skin fold with a quick, firm action

9. Inject and hold for at least 10 seconds

10. Withdraw the needle quickly and apply pressure over the injection site with a dry, sterile pad

11. Put back the protective cap of the needle carefully.

12. Discard the syringe in a sharp bin. If you do not have one, a thick container would do (such as a milo tin or used laundry bottle). Do not discard it in household waste.

Storing and Transporting ESA from pharmacy to home

To protect the medication in Recormon®, here are some important things to take note of:

Storage

All types of ESA, including Recormon®, should be stored and maintained at 2-8 degree Celsius (in refrigerator), be protected from light and not be frozen. As such, you should not keep Recormon® at the frozen section, refrigerator door or the vegetable compartment. It’s best to keep Recormon® in the middle section of the refrigerator and ensure there is proper air circulation around Recormon®. Once Recormon® is out of the fridge, it can only be used up to 3 days before damage. Hence, do not take it out from the refrigerator unless it is time for use.

Transport

Whenever you’re going to refill your Recormon® prescription at the pharmacy, make sure you bring along a cool box/bag with an ice pack inside. Get a decent-sized cool box/bag so that it has enough room to contain all the Recormon® prefilled syringes, as they can be quite bulky in large quantities.

You should return home immediately after getting your Recormon® from the pharmacy and quickly store them into your refrigerator.

What should you be cautious about?

ESA is generally safe to use. Some of the mild and common side effects are irritation at injection site,headache, joint and muscle pain as well as high blood pressure. If you experience any intolerable side effects, seek advice from your pharmacist or the medical personnel at your dialysis unit.

If the doctor asked you to self-inject Recormon® at home, please make sure you also get yourself a blood pressure meter at home so that you can measure your blood pressure prior to injections. Clarify with your doctor the target blood pressure you should achieve before injecting Recormon®. Generally, a person whose blood pressure is above 160/100mmHg should not inject any ESA. 

A rare but serious adverse reaction associated with ESA is known as pure red cell aplasia (PRCA). PRCA can happen in a small group of patients receiving ESA, of which their body produces neutralising anti-erythropoietin antibodies that destroys their own very young red blood cells in the bone marrow. PRCA can be life-threatening and people who have suspected PRCA should discontinue ESA treatment and never receive another type of ESA.

If you suddenly experience joint pain, muscle pain, sudden tiredness, dizziness or sudden shortness of breath following ESA therapy, inform your doctor immediately.

A word from Doc2Us

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References

1. KDIGO Clinical Practice Guideline for Anemia in Chronic Kidney Disease 2012

2. Roche - Recormon® Product Leaflet (Malaysia)

3. Pharmacy Board Malaysia - PRCA Monitoring Guideline

Cover image credit: Desmond Talkington, Flickr via CC BY-NC-SA 2.0

Written by

Ms Joyce Toh