What orders should be placed for a patient with impaired renal function (eGFR 52), anemia (hemoglobin 9.7), leukopenia (WBC 2.8), and elevated alkaline phosphatase (158 U/L)?

Immediate Orders for SNF Patient with Stage 3b CKD, Anemia, Leukopenia, and Elevated Alkaline Phosphatase

Order a comprehensive anemia workup including iron studies (serum iron, TIBC, ferritin, transferrin saturation), vitamin B12, folate, reticulocyte count, and peripheral blood smear to identify the cause of her hemoglobin of 9.7 g/dL. 1

Anemia Management (Priority #1)

Your patient has significant anemia (Hgb 9.7 g/dL) in the context of Stage 3b CKD (eGFR 52 mL/min/1.73 m²), which requires immediate evaluation and treatment:

Initial Workup Orders:

• Iron studies panel (serum iron, TIBC, ferritin, transferrin saturation) - essential first step per KDOQI guidelines for any CKD patient with hemoglobin <12 g/dL in women 1
• Vitamin B12 and folate levels - to exclude nutritional deficiencies 1
• Reticulocyte count - to assess bone marrow response 1
• Peripheral blood smear - the elevated RDW (26.0%) suggests mixed anemia etiologies requiring morphologic evaluation 1

Anemia Treatment Based on Workup:

• If iron deficiency identified (ferritin <100 ng/mL or transferrin saturation <20%), initiate oral or IV iron supplementation 1
• If iron replete and anemia persists, consider erythropoiesis-stimulating agent (ESA) therapy given her eGFR <60 mL/min/1.73 m² 1
• Target hemoglobin should be 10-12 g/dL (avoid targeting >13 g/dL due to increased cardiovascular risks) 1

Leukopenia Evaluation (Priority #2)

Her WBC of 2.8 K/uL with absolute lymphopenia (0.3 K/uL) requires investigation:

Orders:

• Medication review - identify any myelosuppressive agents that should be dose-adjusted or discontinued 2
• Repeat CBC in 1 week - to determine if this is persistent or transient 1
• Consider infectious workup if febrile or symptomatic (blood cultures, urinalysis with culture, chest X-ray if respiratory symptoms) 2
• Hold off on hematology referral unless WBC continues to decline or patient develops recurrent infections 1

Elevated Alkaline Phosphatase Investigation (Priority #3)

ALP of 158 U/L (elevated) with normal transaminases suggests either bone or biliary pathology:

Orders:

• Intact parathyroid hormone (iPTH) level - secondary hyperparathyroidism is common with eGFR <60 mL/min/1.73 m² and can cause elevated ALP and worsen anemia 1, 3
• 25-hydroxyvitamin D level - vitamin D deficiency is prevalent in CKD and contributes to secondary hyperparathyroidism 1
• Calcium and phosphorus levels - already obtained (calcium 8.70 mg/dL is low-normal, phosphorus not listed but should be monitored) 1
• If iPTH >100 pg/mL, initiate treatment per CKD-MBD guidelines 1

Hypoalbuminemia Management (Priority #4)

Albumin of 3.4 g/dL (low) and total protein 5.7 g/dL (low) indicate malnutrition or protein loss:

Orders:

• 24-hour urine collection for protein quantification - to assess for nephrotic-range proteinuria 1
• Spot urine protein-to-creatinine ratio - if 24-hour collection not feasible 1
• Nutritional consultation - for protein supplementation strategy 1
• Protein target: Given eGFR 52 mL/min/1.73 m² (Stage 3b CKD), target 1.0-1.2 g/kg/day protein intake (not the restricted 0.8 g/kg/day, which is only for eGFR <30 mL/min/1.73 m²) 1

Metabolic Acidosis Monitoring

Bicarbonate of 30 mEq/L is at upper limit of normal, but with eGFR <60 mL/min/1.73 m²:

Orders:

• Continue monitoring serum bicarbonate every 3 months with routine labs 1
• If bicarbonate drops <22 mEq/L, initiate sodium bicarbonate supplementation 1

Ongoing Monitoring Schedule

Continue weekly labs as you've already ordered, but ensure they include:

• CBC with differential 1
• Comprehensive metabolic panel 1
• Calcium and phosphorus 1
• Add to next weekly draw: iPTH, 25-OH vitamin D, iron studies, B12, folate 1

Blood Pressure Management

Her sodium is 145 mEq/L (upper limit), suggesting possible volume issues:

Orders:

• Blood pressure monitoring at every visit (should be at least weekly in SNF) 1
• Target BP <130/80 mmHg for CKD patients 1
• If hypertensive, ensure ACE inhibitor or ARB is first-line agent (monitor creatinine and potassium closely after initiation) 1

Critical Caveats

• Do not restrict protein to 0.8 g/kg/day - this is only for eGFR <30 mL/min/1.73 m², and her eGFR is 52 mL/min/1.73 m² 1
• Avoid nephrotoxic medications - review all medications for renal dosing adjustments, particularly antibiotics like ceftriaxone which may require monitoring but typically no dose adjustment at this eGFR 2
• The combination of anemia, leukopenia, and elevated ALP could suggest bone marrow pathology or severe secondary hyperparathyroidism - the iPTH level will be crucial 3
• Monitor for infection closely given leukopenia and SNF setting 2