Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.  

Sara is a 75-year-old woman with a 40-year history of hypertension and a 30-year history of type two diabetes and dyslipidemia, who was recently diagnosed with stage four chronic kidney disease, a.k.a. CKD. Given this history, which of the following hemograms would be expected? And before we start, as I go through the options here, I just want to remind you for these case scenarios, hemoglobin norm is 12 to 14 grams, MCV is 80 to 96, and RDW for the norms are 11.5-15%. So, keep that in mind as we're going through the case scenarios here. 

Option A: Hemoglobin 9.7, MCV of 69, so microcytic, RDW elevated at 18%, telling us the new cells are even more microcytic than the old red blood cells.  

Option B: Hemoglobin 7.2 So more profound anemia. MCP 122, a marked macrocytosis. RDW 18.1% telling us the new cells are even more macrocytic than existing in older cells. 

Option C: Hemoglobin 9.4 MCV 83. So that's within normal limits. That's a normocytic anemia. If an anemia is normocytic it will also be normochromic. RDW 13% telling us that new cells and old cells are roughly the same size and  

Option D: Hemoglobin 10.4, MCV 82. So that’s normocytic, normocytic would mean normochromic and RDW 18%. The correct answer here is C. I'd be willing to bet you're exhausted from just going through all those lab options. And where do you start? 

First, determine what kind of a question this is. Given that we're provided with the diagnosis of stage four CKD, this question can be viewed as an assessment question where the clinician is investigating additional data in a person with an established diagnosis. 

Now let's take a look at the background information. CKD is reported in five stages one, two, three, four, and five. And advanced CKD, particularly stages four and five, anemia of chronic disease, is quite common. This patient has many of the major risk factors for CKD, which include long standing hypertension. And hypertension is the most commonly reported risk factor for CKD as well as dyslipidemia and type two diabetes. When looking at the anemia, keep in mind how CKD is diagnosed. It’s usually diagnosed based on a number of factors, including the presence or absence of albuminuria, the GFR, and the anticipated or suspected cause of the CKD. There are likely multiple contributors to the anemia that goes along with CKD. One major influence is the reduction in renal erythropoietin production. And erythropoietin, if you will recall, you all heard about this in pathophysiology and anatomy and physiology at some time. It's produced largely by the kidney. About 90% of the erythropoietin in a healthy person with healthy kidneys comes from the kidney, and about 10% comes from the liver. Erythropoietin is put into circulation and binds with receptors in the bone marrow that help to stimulate the production of erythrocytes or red blood cells. And once the GFR is less than 49, and keep in mind that the GFR in a younger, healthier adult is around 90 to 120 or more, renal erythropoietin production is reduced. In end stage for CKD, the GFR is profoundly reduced to a range of around 15 to 29. 

In addition, as is common in a variety of chronic illnesses, the anemia that goes along with CKD, the red blood cell lifespan is short. These factors result in normocytic normochromic anemia with a normal limit RDW. As a reminder that if red blood cells are normal size, normocytic, normal color, normochromic and all around the same size, normal limit RDW. Anemia caused by micronutrient deficiency including iron folate or folic acid deficiency and B12 deficiency have been largely ruled out. People with CKD often have other significant health problems, as we could see with this particular patient. Therefore, ongoing evaluation for superimposed additional anemia forms and a person with CKD, particularly in dialysis, as part of the treatment plan is important. The care of the person with CKD, particularly advanced disease like this is quite complex and requires expert care from a team who can address many of the ongoing issues here. So, with that background, you might think that this is a question that's incredibly challenging. 

However, once again, if you break down the answers correlate with the likely anemia types represented in each question, choice or answer, and consider the clinical information that's been given as well as, and I’m going to say it again, patient risk factors for each anemia type, the correct answer becomes really much, much clearer. So you might first glance at that and say, Oh, this is a really specific question about a person with CKD and when you dig a little bit deeper, what you find out is this is diagnosing a person who has a type of anemia of chronic disease, but to answer that correctly, you need to know that anemia is commonly correlated with advanced CKD. So let's go back and take a look at the question and go through the answer. Options provided.  

Sarah is a 75-year-old woman with a 40-year history of hypertension, a 30 year history of Type two diabetes and dyslipidemia who was recently diagnosed with stage four CKD. Given this history, which of the following hemograms would be expected? 

A hemoglobin of 9.7 MCV of 69. So microcytic, RDW 18% telling us the new red blood cells are likely smaller and paler than the existing red blood cells. This is incorrect, this hemogram, reporting the findings that I just said, is more indicative of a developing iron deficiency anemia. Where iron deficiency anemia increase can occur, it usually is associated with other factors that result in chronic low volume blood loss because chronic low volume blood loss in the adult is the most common reason for iron deficiency anemia. 

Option B: Hemoglobin 7.2 MCV the of 122, a marked macrocytosis. RDW 18.1% telling us that the new cells are different size than existing cells, perhaps even bigger than the existing cells. This is also incorrect. 

Here is a really rather significant anemia with that marked macrocytosis with the elevated RDW. This scenario is more consistent with vitamin B12 deficiency. The most common cause of hemogram such as that in this patient's scenario, we are really being asked to identify an anemia that would most likely be reported in CKD. And if you are thinking yeah, but couldn't she have B12 deficiency with pernicious anemia being the most common form of B12 deficiency? Yeah but couldn't she have more than one thing going on? You're absolutely right on that. 

However, we probably would also be given additional information such as she has peripheral neuropathic changes that are new. That's quite common with B12 deficiency and oral mucosal irritation. There would be a number of other things that would be presented to us at the same time.  

Option C as we know is the correct answer where the hemoglobin is, 9.4 MCV is 83. 

So it's a normocytic normochromic anemia. RDW 13%; new cells, old cells, roughly the same size. The anemia seen with CKD is usually noticed in the absence of micronutrient deficiency or chronic low volume blood loss. As mentioned, the reduced erythropoietin supply, along with select other factors, are major contributors. 

Now the last option. Option D we already ascertained C is the correct answer, but we want to go over D as well. Hemoglobin 10.4 MCV is 82, so that's normocytic, normochromic. But please note the RDW is elevated at 18%. So what is that telling me? That's telling me right now the MCV size is okay, but remember MCV is mean corpuscle volume or mean cell volume. It's that average of the cell size. So, this option represents the scenario of an early microcytic anemia such as IDA are an early macrocytic anemia such as B12 or folate deficiency. 

And all we know here is that the new cells are a different size when compared to the older cells. And what we would have to do if we had a patient with a hemogram like that, we would have to figure out what was going on.  

Key takeaway has been pointed out in many of these podcasts. Certain clinical conditions occur more commonly in people with certain risk factors. Correlating risk factors with anticipated disease outcomes is a critical factor in your clinical assessment. 

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