Addressing Hormone-Dependent Anemia in a 52-Year-Old Woman with Chronic Kidney Disease – Expanded Details

Patient

 Ms. Fatima, a 52-year-old woman with a history of hypertension and chronic kidney disease (CKD) diagnosed five years ago. She lives in a rural area with limited access to healthcare specialists.

Presenting Complaint

Ms. Fatima presented with progressive fatigue, shortness of breath on exertion, and dizziness for the past three months. These symptoms significantly impacted her daily activities and quality of life. She described feeling weak while tending to her vegetable garden, her primary source of income.

Medical History:

• Hypertension for 10 years, managed with medication (lisinopril).
• CKD diagnosed five years ago, currently on Stage 3 with an estimated GFR of 45 ml/min/1.73 m².
• No history of diabetes, malignancy, or blood transfusions.
• Family history of hypertension and CKD.
• Limited access to specialists and diagnostic facilities due to her rural location.

Investigations:

• Laboratory tests:
  • Anemia with Hb of 9.5 g/dL (normal range: 12-16 g/dL) and Hct of 28% (normal range: 36-48%).
  • Serum iron within normal range.
  • Vitamin B12 and folate levels slightly low.
  • EPO level suppressed at 2 mU/mL (normal range: 8-32 mU/mL).
• Physical examination:
  • Pale skin and mucous membranes.
  • Tachycardia (resting heart rate 100 bpm).
  • Mild edema in the lower extremities.

Diagnosis: Hormone-dependent anemia secondary to CKD, likely exacerbated by mild vitamin B12 and folate deficiencies.

Treatment Plan:

• rEPO therapy: Initiated at a starting dose of 75 IU/kg three times per week, with adjustments based on Hb and blood pressure monitoring.
• Iron supplementation: Oral iron prescribed to address borderline iron stores.
• Vitamin B12 and folate supplementation: Injectable B12 and oral folate supplements to address deficiencies.
• Blood pressure monitoring: Close monitoring of Ms. Fatima’s blood pressure with potential dose adjustments of lisinopril if needed.
• Nutritional counseling: Dietary guidance focused on increasing iron-rich foods (lentils, spinach), fruits and vegetables for vitamin B12 and folate, and maintaining adequate hydration.
• Education and self-management: Ms. Fatima was trained on recognizing early signs and symptoms of anemia and potential side effects of rEPO therapy.
• Referral to a nephrologist: A referral was made to a nephrologist in a nearby city for further evaluation and management of her CKD.

Outcomes:

• After two months of rEPO therapy, Ms. Fatima’s Hb increased to 12.5 g/dL, and her fatigue and shortness of breath significantly improved.
• Her blood pressure remained within acceptable limits.
• Ms. Fatima reported feeling more energetic and able to work longer in her garden, improving her income and well-being.

Challenges and Considerations:

• Balancing the benefits of rEPO with potential risks like hypertension and thromboembolic events required close monitoring and dose adjustments.
• Adherence to medication and follow-up appointments was crucial for long-term success, especially with limited access to specialists.
• Addressing Ms. Fatima’s underlying CKD and managing her comorbidities remained essential for long-term anemia control.
• Providing ongoing education and support to empower Ms. Fatima to manage her condition effectively in her rural setting.

Conclusion:

This expanded case study illustrates the complexities of managing hormone-dependent anemia in a resource-limited setting. It highlights the importance of a holistic approach that considers the underlying cause of anemia, addresses nutritional deficiencies, monitors potential side effects, and empowers patients through education and self-management strategies. By adapting treatment plans to individual circumstances and collaborating with local healthcare providers, rEPO therapy can significantly improve the quality of life for patients with this condition, even in challenging environments.

This expanded case study provides more details about Ms. Fatima’s situation, including her living conditions, family history, and access to healthcare. It also elaborates on the rationale behind the treatment plan, the challenges faced, and the importance of patient education and empowerment. I hope this additional information is helpful.