I just finished this article (registration required) about anemia in people with Chronic Renal Failure. They found out that if you raise their hemoglobin too high, you have problems.

Well, I’ll translate that into English for you.

In the “good old days”, we gave a lot of blood for people who had low blood counts.

I’m not talking about people with ulcers or who had accidents and lost blood, but about people who for some reason couldn’t make their own blood. Back then, we often would have old ladies who just got anemic. Some had bleeding that they were too frail to fix (like diverticulosis or ulcer or even a slow growing cancer). Some had sluggish kidneys, and some had arthritis of one sort or another. And some just seemed to be worn out: poor nutrition, frail, weak, but no cancer, so we just treated them. We called it “pooped out bone marrow”. Not scientific, but a good description since many just didn’t manage to make enough blood.
So every three months or so, we’d put grandmom in the hospital overnight for a couple pints of blood, and send her home the next day. She’d go from a frail, weak old lady to one ready to hit the bingo games, full of energy.

What happened then, of course, was AIDS and HIV which was spread by blood transfusions.
And then, a miracle: Epogen. That medicine and several newer versions of it.

All these drugs are forms of the kidney hormone that encourages your body to produce the red blood cells that carry oxygen.

The first patients we used this on were those with kidney failure. When your kidneys fail, you get anemic. The fatigue of mild azotemia from the failing kidneys was bad enough (i.e. you felt lousy all the time), but add anemia and you are a basket case.

But if you transfuse someone with bad kidneys, they might get too much fluid on board, and the fluid would fill up their lungs. Medically this is called pulmonary edema, and can kill you.

The shot was marvelous, but very very expensive. When we first used it, we just raised their blood count to keep them alive. But with time, larger doses were used. We found that keeping their Hemoglobin to 7 kept them alive, keeping it at 9 let them feel okay, but raising it to 12 made them feel even better.

Alas, the study I linked to shows the problem: Get the blood count much over 12, and some get fluid in thier lungs, the thicker blood clots more easily and leads to heart attacks.

So now the agreement of docs (and the insurance companies that pay for the drug) is to keep the blood count about 11. High enough to feel good, but not too high.

LINK is a summary of what we use these shots for.

Just an added note. Remember the old ladies I mentioned in the beginning? Some had mild kidney failure and responded. And, of course, we also commonly use it for people who are on chemotherapy, which also knocks out the ability of the bone marrow to make new blood. But a lot now are recognized to have bone marrow problems (sometimes unknown causes, some have low risk myelodysplasia, some chronic disease like Rheumatoid arthritis). In some of these old ladies, if the investigation and bone marrow shows one of these disease, we can just give them shots to prevent anemia.

Another high cost but life saving modern medicine that helps people live better quality lives.

One of the last patients I treated with weekly shots was a kind gentleman whose myeldysplasia, which we had treated for years with shots, suddenly transformed to acute leukemia. (one complication of that condition). We arranged hospice, and for his church to pray over him, and then our job was to keep him comfortable. But we continued to see him weekly, using the excuse to give him these expensive shots, mainly because his wife found getting him out of the house was good for him.

The gentleman was expected to die within weeks, but he kept holding on, to all of our amazement. Then one day, I discussed with him about end of life care, and the need to finish his work on earth before going to the Lord. And then I found his real worry. He was ready to die, but had not one but two sons in Afghanistan, and he didn’t want to die before he was sure they were safe.

So we called the Red Cross and arranged for them to come home. And our patient? He died peacefully in his sleep the day their plane arrived in Tulsa.

There are some things that even medicine can’t explain.

Nancy Reyes is a retired physician living in the Philippines with her husband. Her website is finest kind clinic and fishmarket and she often posts medical essays to Hey Doc’s Xanga blog

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