SMJR

TREAT. A Trial of Darbepoetin Alfa in Type 2 Diabetes and Chronic Kidney Disease. NEJM 2009; 361: 2019.

We know from the Hebert et al (NEJM 1999, Crit Care Med 2001) that most critically ill patients with anemia should be transfused to maintain a hemoglobin of 7.0-9.0 g/dL and Wu et al (NEJM 2001) showed that elderly people with myocardial infarctions should be transfused to maintain a hematocrit between 30-33%, therefore, should critically ill patients with ESRD be transfused to maintain a hemoglobin between 11-12.0 g/dL, and if not, what should that target be?

KDOQI Clinical Practice Guideline and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease: 2007 Update of Hemoglobin Target

A 68 year old man with hypertesion treated with HCTZ comes for an annual physical exam.

On examination, temperature is normal, BP is 139/84, HR 87 bpm, and RR 16/min. The patient has rosy cheeks. There is no JVD, cardiopulmonary exam is normal, and spleen tip is palpable just below the left costal margin.

Lab

Hematocrit: 61%

Leukocyte count: 11,200/microL
Platelet count: 405,000/microL
Erythropoietin: 10 mU/mL
Arterial oxygen saturation: 96% (on room air)
Cytogenetic studies: positive JAK2 mutation

 

What is the most appropriate therapy?

A) Therapeutic phlebotomy
B) Therapeutic phlebotomy plus anagrelide
C) Therapeutic phlebotomy plus aspirin
D) Therapeutic phlebotomy plus hydroxyurea

This is an 87 year old man who has a protracted hospital stay complicated by ESBL and VRE UTI, c. difficile colitis, MRSA and pseudomonal pneumonia who has had chronic anemia now having acute respiratory distress and rapidly worsening anemia (hemoglobin drop from 9.8 g/dL to 6.9 g/dL). He has had hematuria for five days. A CT scan was done, see below, what is the next step?

This is a 53 year old man who uses crack cocaine and has hypertension and hepatitis C. He was seen at another hospital seven days prior to this admission with chest pain. His EKG is provided below. He was discharged on indomethacin, colchicine, and ciprofloxacin. He has continued chest pain and malaise. His troponin level is 1.85 ng/mL. He is admitted to the telemetry monitoring and has continued chest pain. His morning EKG is provided below and now his troponin level has gone from 3.58 ng/mL to 6.20 ng/mL.