DIABETES
Even those patients whose diabetes is well controlled are at risk for kidney disease -- 20-30% of people with Type 1 or Type 2 Diabetes develop kidney problems within 15 years of diagnosis. It starts with small amounts of protein in the urine, which usually appear after 10 years. If protein content reaches 30 mg/dl, usually 15-20 years after diagnosis, it is called nephropathy.

MEDICINES -- HOW WE HELP
EPREX® (Epoetin alfa) often is prescribed for people who are anemic from Chronic Kidney Disease. The increase in red blood cells takes place gradually and depends on your individual response to the medication. EPREX® brand of Epoetin alfa

I. ABOUT DIABETES AND KIDNEY DISEASE
Diabetes is the No. 1 cause of chronic kidney failure in America, accounting for more than 35% of new cases annually (about 13,000 people) and 25% of all cases. The two most common types of diabetes are Type 1 (insulin-dependent diabetes mellitus or IDDM), when the pancreas cannot produce insulin, and Type 2 (non-insulin-dependent diabetes mellitus or NIDDM), when the pancreas produces insulin but the body cannot properly use it. Type 1 is usually diagnosed during childhood; Type 2 is far more common. It is thought that kidney failure strikes both groups almost equally.1 The risk of kidney disease developing in diabetic patients increases with time. About 60% of patients who have Type 1 diabetes for 20 to 30 years develop kidney disease, while 10-40% of those with Type 2 progress to severe kidney disease and end-stage renal disease (ESRD).

Diabetes develops from two factors -- a genetic predisposition and a "second event." In Type 1 diabetes, the second event could be a viral infection like chickenpox. In Type 2, the second event is usually obesity.1

Because there is no cure for kidney disease, controlling and slowing it are crucial. Controlling hypertension (high blood pressure), the most important predictor of which diabetics will develop kidney disease, is extremely important, as are watching blood sugar levels and reducing dietary protein intake. Other control-oriented treatments used include preventing urinary tract infections, losing weight, and avoiding medications that might cause kidney damage.

Signs that someone with diabetes might be developing kidney disease include:

·  High blood pressure (hypertension)
·  Protein in the urine
·  Increased need to urinate, particularly at night

·  Leg swelling or cramps

·  Abnormal blood tests (e.g., a rise in blood urea nitrogen)

·  Less need for insulin

·  Nausea and vomiting

·  Weakness, fatigue, and anemia

Reference: 1. National Kidney Foundation: More Facts About Diabetes. On the Internet: http://www.kidney.org/general/aboutdisease/diab. cfm. Accessed Nov. 18, 1999.

I. THE MORE YOU KNOW THE BETTER YOU CAN MANAGE
Most cancer patients not only have to cope with their disease but with other symptoms as well, such as nausea, vomiting, tiredness, or fatigue. Fatigue is often a side effect of many cancer treatments, such as when chemotherapy depletes red blood cell levels so greatly that anemia develops. If you are fatigued, talk to your doctor about whether anemia may be the cause. Anemia can be treated! Blood transfusions are used to treat severe anemia, but may cause allergic reactions, fevers, chills, infections, and headaches. In addition, blood transfusions may be inconvenient, costly, and time-consuming. Therapy with EPREX® (Epoetin alfa) is an alternative treatment for anemia. Epoetin alfa increases the number of red blood cells in your body by mimicking the natural substance in your body that spurs RBC production.

ON THIS WEBSITE
In addition to sections designed to help you better understand anemia and fatigue, this site also provides suggestions on ways to discuss your concerns and options with health care professionals. You'll also find helpful hints on how to manage your anemia and fatigue so that you can help yourself feel better and make your life easier. Commonly asked questions about anemia and fatigue follow. We hope you will learn about treatments and ways of coping that can enable you to perform the activities you want and need to do.

WHAT IS FATIGUE?
Everyone has experienced tiredness and expects it to go away after a good night's sleep. Fatigue is a much greater degree of tiredness. It is an unusual or excessive feeling of tiredness that is not easily relieved by sleep. Fatigue occurs when you feel more tired than usual or tire more quickly after completing usual activities. It also may occur when you are not doing anything. Fatigue can be more than just a feeling of being constantly tired. You also may experience difficulty performing everyday activities such as housework, showering, and cooking. Difficulty in walking, talking, concentrating, and making decisions all may be symptoms of fatigue. Sometimes, you just do not feel like yourself. Often, it is difficult trying to deal with family members or other people who may be trying to help you.

WHAT CAUSES FATIGUE?
Fatigue is one of the most common symptoms associated with cancer and cancer therapies. The chemotherapeutic agents lessen the bone marrow's ability to make red blood cells. This lack of RBCs, or anemia, can cause you to feel extremely tired. Adding to this might be such factors as emotional stress, coping with anxiety, conflict, sadness, even tension among loved ones, which require extra energy. Changes in your daily routine also contribute to fatigue. As a result of your cancer treatment, your sleeping, eating, and working patterns may change. The fact is, your entire life is being turned upside down and yet so much is still expected of you. You still have to travel to and from treatments. You still have to function. You still have to cope. You have to call upon your body to do so much more than it may want to do or be able to do.

Blood is composed of cells that move around in a watery substance called plasma. The three basic types of cells in blood are red cells, white cells, and platelets. It works like this: Your body uses oxygen to produce energy. The hemoglobin (Hb) in red blood cells carries oxygen to all parts of the body, providing the energy needed fo normal activities, and they remove carbon dioxide. When you are anemic, less oxygen reaches your muscles and organs like your heart. Not having enough red blood cells to carry oxygen places extra demands on your body.

White cells fight infection and harmful substances that invade the body. Platelets help stop bleeding by plugging leaks in blood vessels. It takes all three working together properly to perform vital bodily tasks. To know how your blood cells are working, a complete blood count (CBC) measures the levels, or counts, of the different types of cells in the blood. Because cancer and its treatments can cause blood counts to drop, a CBC is one of the most important tests that people with cancer routinely get. Regular CBC testing can help catch a low or high blood count so it can be treated before it becomes serious. Like many drugs, EPREX® (Epoetin alfa) takes time before you feel a difference. With regular CBC tests, you may be started on EPREX®  before your anemia gets too serious.

KNOW YOUR Hb COUNT
If you have cancer, especially if you're receiving chemotherapy, it's important for you to know your Hb count. The normal Hb count (or level) is:

·  14 g/dL to 18 g/dL for men

·  12 g/dL to 16 g/dL for women

·  If your Hb count is lower than the normal range and you always feel tired, ask your doctor about treatment to raise your Hb count.

Hemoglobin is measured in grams (g) per deciliter (dL). The average hemoglobin value for men is 16 g/dL and for women is 14 g/dL. However, the definition of "normal" varies from person to person. If your hemoglobin is outside the normal range, contact your health care provider.

Hemoglobin is measured in grams (g) per deciliter (dL). The average hemoglobin value for men is 16 g/dL and for women is 14 g/dL. However, the definition of "normal" varies from person to person. If your hemoglobin is outside the normal range, contact your health care provider.

Hemoglobin is measured in grams (g) per deciliter (dL). The average hemoglobin value for men is 16 g/dL and for women is 14 g/dL. However, the definition of "normal" varies from person to person. If your hemoglobin is outside the normal range, contact your health care provider.

Hemoglobin is measured in grams (g) per deciliter (dL). The average hemoglobin value for men is 16 g/dL and for women is 14 g/dL. However, the definition of "normal" varies from person to person. If your hemoglobin is outside the normal range, contact your health care provider.

Hemoglobin is measured in grams (g) per deciliter (dL). The average hemoglobin value for men is 16 g/dL and for women is 14 g/dL. However, the definition of "normal" varies from person to person. If your hemoglobin is outside the normal range, contact your health care provider.

Hemoglobin is measured in grams (g) per deciliter (dL). The average hemoglobin value for men is 16 g/dL and for women is 14 g/dL. However, the definition of "normal" varies from person to person. If your hemoglobin is outside the normal range, contact your health care provider.

MORE ABOUT Hb AND Hb COUNTS
Hemoglobin (Hb) is vital because it carries oxygen to all parts of your body.

WHERE IS IT?
Hb is in the red cells in your bloodstream

WHY IS IT IMPORTANT?
Your body needs fuel to run, just like a car. The oxygen carried by Hb is the fuel your body needs to stay active.

CAN I COUNT ON IT?
Normally your body makes enough red cells. But some things can keep your body from making enough red cells. If this happened, your Hb count would drop and your body wouldn't get enough oxygen. Chemotherapy to treat cancer can cause this. A shortage of nutrients such as iron, vitamin B12, and folic acid also can lower Hb counts.

WHAT HAPPENS WHEN THERE'S NOT ENOUGH?
Anemia develops. Over time, you would become tired physically and mentally. Have you ever held your breath for longer than a minute? Do you remember how tired you were afterward? With anemia, you would feel tired all the time. Even extra sleep wouldn't help you feel better.

HOW CAN I CHECK IT OUT?
Ask your doctor for a blood test to check your Hb. Normal Hb counts, or levels, are 14-18 g/dL for men and 12-16 g/dL for women.

CAN IT GO BACK UP?
There are ways you can get your Hb count back up to normal. Your doctor will help you decide which way is best for you.

TAKING CHARGE OF YOUR HEALTH: HAVE YOUR Hb CHECKED REGULARLY

·  Seek nutritional advice about including iron- and vitamin-rich foods and supplements in your diet

·  Plan your activities to save energy and prevent fatigue

·  Be informed about all of your medicines and treatments, including what they do and their side effects

·  Be sure to ask your doctor if you have any questions about your disease and/or treatment

CHEMOTHERAPY AND ANEMIA

Anemia is a side effect experienced by more than 60% of patients undergoing chemotherapy. The condition, a low level of red blood cells, is characterized by feelings of weakness, fatigue, dizziness, irritability, shortness of breath, and chills. Why does it happen? Because chemotherapy drugs can reduce the bone marrow's ability to make red blood cells. Red blood cells carry oxygen to all parts of the body, providing the energy needed for normal activities.

·  Chemotherapeutic agents kill all rapidly dividing cells, both cancerous and healthy, including blood cells
·  Chemotherapy not only destroys red blood cells, it suppresses the bone marrow's ability to produce new ones, causing anemia
·  The hemoglobin in red blood cells carries and releases oxygen throughout the body. Oxygen acts like fuel for the body, providing energy for muscles and organs to work
·  Energy levels can plummet due to lack of oxygen-rich red blood cells

·  Chemotherapeutic agents kill all rapidly dividing cells, both cancerous and healthy, including blood cells
·  Chemotherapy not only destroys red blood cells, it suppresses the bone marrow's ability to produce new ones, causing anemia
·  The hemoglobin in red blood cells carries and releases oxygen throughout the body. Oxygen acts like fuel for the body, providing energy for muscles and organs to work
·  Energy levels can plummet due to lack of oxygen-rich red blood cells

·  Chemotherapeutic agents kill all rapidly dividing cells, both cancerous and healthy, including blood cells
·  Chemotherapy not only destroys red blood cells, it suppresses the bone marrow's ability to produce new ones, causing anemia
·  The hemoglobin in red blood cells carries and releases oxygen throughout the body. Oxygen acts like fuel for the body, providing energy for muscles and organs to work
·  Energy levels can plummet due to lack of oxygen-rich red blood cells

·  Chemotherapeutic agents kill all rapidly dividing cells, both cancerous and healthy, including blood cells
·  Chemotherapy not only destroys red blood cells, it suppresses the bone marrow's ability to produce new ones, causing anemia
·  The hemoglobin in red blood cells carries and releases oxygen throughout the body. Oxygen acts like fuel for the body, providing energy for muscles and organs to work
·  Energy levels can plummet due to lack of oxygen-rich red blood cells

·  Chemotherapeutic agents kill all rapidly dividing cells, both cancerous and healthy, including blood cells
·  Chemotherapy not only destroys red blood cells, it suppresses the bone marrow's ability to produce new ones, causing anemia
·  The hemoglobin in red blood cells carries and releases oxygen throughout the body. Oxygen acts like fuel for the body, providing energy for muscles and organs to work
·  Energy levels can plummet due to lack of oxygen-rich red blood cells

·  Chemotherapeutic agents kill all rapidly dividing cells, both cancerous and healthy, including blood cells
·  Chemotherapy not only destroys red blood cells, it suppresses the bone marrow's ability to produce new ones, causing anemia
·  The hemoglobin in red blood cells carries and releases oxygen throughout the body. Oxygen acts like fuel for the body, providing energy for muscles and organs to work
·  Energy levels can plummet due to lack of oxygen-rich red blood cells

When anticancer drugs keep blood cells from getting the oxygen they need, the cells are unable to do their job, and patients are more likely to feel the debilitating effects of fatigue.

To support normal movement in anemic patients, the heart tries to make up for the shortage of oxygen in the blood. It works harder to move the red blood cells more quickly and deliver oxygen faster. This increased workload can put an additional burden on the heart. Thus, you are most likely to feel the effects of anemia during any kind of physical activity.

MANAGING SIDE EFFECTS

Your doctor will check your blood count often during treatment. If your red count falls below normal levels, you may need a medication, EPREX® (Epoetin alfa), that works to increase the number of red blood cells in your body. Therapy with EPREX ® can prevent the need for a blood transfusion. Your doctor has chosen chemotherapy as an appropriate plan of attack for you. To prepare for the process, it's important that you learn as much as possible about the treatment so that you can make the most out of it, and learn how to combat the side effects you may experience. It would be ideal if health care professionals could treat only the areas where the cancer is present. Unfortunately, that's not always possible. Because healthy tissues also may be damaged during chemotherapy, treatment can cause some unpleasant side effects. Such side effects vary from person to person, and may be different from one treatment to the next. The good news is that most side effects go away as soon as your treatment is over. It works like this: Anticancer drugs - such as those used for chemotherapy - affect rapidly dividing cells. Cells in hair follicles and those that line the digestive tract, for example, are normal cells that divide quickly. This is why chemotherapy patients are prone to lose hair and experience nausea, vomiting, diarrhea, or mouth sores.

COMMON CHEMOTHERAPY SIDE EFFECTS

·  nausea and vomiting

·  hair loss

·  diarrhea/constipation

·  infections

·  bleeding

·  anemia

·  fatigue

·  pain

REDUCING SIDE EFFECTS OF ANEMIA
Beyond your EPREX® therapy, there are some other things you can do to alleviate the side effects of anemia:

·  Rest. Sleep more at night and take naps during the day if you can.

·  Limit activities. Do only the things that are most important to you.

·  Ask for help. Don't be bashful about asking family and friends to pitch in with things like child care, shopping, housecleaning, or driving.

·  Eat a well-balanced diet. While you are in the hospital or outpatient center, members of the food or nutrition service can help you plan your diet. Also, the National Cancer Institute (NCI) publishes a booklet called "Eating Hints for Cancer Patients." See the back of this booklet for NCI's number.

·  Move slowly. Remember to get up slowly when sitting or lying down. This helps avoid dizziness.

QUESTIONS YOU CAN ASK YOUR DOCTOR

FATIGUE/ANEMIA QUESTIONS AND ISSUES

·  Is it normal to feel tired or very weak on chemotherapy?

·  How can you determine the cause of my tiredness or weakness?

·  Could I be anemic?

·  What is my hemoglobin level (and/or red blood cell count)?

·  If I am anemic, what treatments are available? Other issues to discuss:

·  I have problems sleeping.

·  I have questions about my medicine