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Anemia of chronic kidney disease



Anemia of CKD is usually normocytic, normochromic, and hypoproliferative, which increases as the kidney disease progresses.
Anemia of CKD is mostly caused by a relative deficiency in EPO (EPO) production. Other causes include inflammation, iron deficiency, and accumulation of uremic toxins.
Disease course
Decreased production of EPO due to worsening kidney function results in anemia of CKD, which causes clinical manifestations of decreased QoL, cognitive impairment, sleep disturbances, CKD progression, and cardiovascular comorbidities.
Prognosis and risk of recurrence
Anemia of CKD among diabetics is associated with higher mortality (HR 3.61, 95% CI 2.48-5.26).


Key sources

The following summarized guidelines for the evaluation and management of anemia of chronic kidney disease are prepared by our editorial team based on guidelines from the Japanese Society of Nephrology (JSN 2019), the United Kingdom Kidney Association (UKKA 2017), the British Committee for Standards In Haematology (BCSH 2013), and the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2012). ...
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Screening and diagnosis

Indications for screening: as per UKKA 2017 guidelines, consider measuring hemoglobin levels at least at following intervals to screen for anemia in patients with CKD:
stage 3: once per year
stage 4-5, non-dialysis: twice per year.
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  • Diagnostic criteria

Diagnostic investigations

Initial evaluation: as per UKKA 2017 guidelines, evaluate all patients with chronic anemia associated with CKD for the cause and possible treatment in case of hemoglobin levels < 110 g/L (< 105 g/L in patients aged < 2 years) or symptoms attributable to anemia, irrespective of the grade of kidney disease or requirement for RRT.
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  • EPO measurement

  • Evaluation for functional iron deficiency

Medical management

Iron therapy: as per JSN 2019 guidelines, consider administering iron therapy in patients with CKD and iron deficiency anemia.

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  • ESAs (initiation)

  • ESAs (choice of agent)

  • ESAs (route of administration)

  • ESAs (dosing)

  • ESAs (maintenance)

  • Treatment targets

  • Adjuvant therapies

Therapeutic procedures

RBC transfusion: as per UKKA 2017 guidelines, avoid administering RBC transfusion where possible to minimize the risk of allosensitisation in patients with anemia of CKD, especially if renal transplantation is an option.
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Specific circumstances

Pediatric patients, iron therapy
As per KDIGO 2012 guidelines:
Administer oral iron (or IV iron in patients with hemodialysis-dependent CKD) when transferrin saturation is < 20% and ferritin is < 100 ng/mL in pediatric patients with anemia of CKD not on iron or ESA therapy.
Administer oral iron (or IV iron in patients with hemodialysis-dependent CKD) to maintain transferrin saturation > 20% and ferritin > 100 ng/mL in pediatric patients with CKD on ESA therapy not receiving iron therapy.

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  • Pediatric patients (ESA therapy)

  • Pediatric patients (treatment targets)

  • Renal transplant recipients

  • Patients with ESA-induced pure red cell aplasia

Follow-up and surveillance

Serial hemoglobin monitoring, patients not on ESA therapy: as per KDIGO 2012 guidelines, measure hemoglobin concentration in patients with anemia of CKD when clinically indicated and at least at the following intervals according to the stage of CKD:
stage 3-5, non-dialysis or peritoneal dialysis: every 3 months
stage 5, on hemodialysis: every month.

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  • Serial hemoglobin monitoring (patients on ESA therapy)

  • Serial iron status monitoring

  • Serial BP monitoring

  • Management of ESA hyporesponsiveness