Management of Anemia in Chronic Kidney Disease
Diagnosis and Initial Evaluation
- Diagnose anemia when hemoglobin is <135 g/L in adult males or <120 g/L in adult females with CKD, and screen all CKD patients for anemia at least annually, with more frequent monitoring needed for diabetic patients 3, 4
- Initial evaluation should include complete blood count, reticulocyte count, iron studies, and assessment for other causes of anemia, to assess bone marrow function and evaluate bone marrow response to anemia 2, 4
Iron Status Assessment
- Hemoglobin is preferred over hematocrit for monitoring anemia due to better reproducibility across laboratories and less susceptibility to storage time and patient variables, and evaluate iron status using serum ferritin, transferrin saturation, and mean corpuscular volume 2, 4
- Consider inflammation's impact on ferritin, and C-reactive protein measurement may help interpret elevated ferritin levels 5, 4
Special Considerations
- Patients with diabetes require more vigilant monitoring due to earlier onset and higher prevalence of anemia at any level of kidney function, and consider evaluating for gastrointestinal bleeding in non-dialysis CKD patients with iron deficiency but without known causes of blood loss 3, 4, 2
- Consider inflammation as a cause of ESA resistance and functional iron deficiency, and newer approaches including hypoxia-inducible factor prolyl-hydroxylase inhibitors are emerging as alternatives to traditional ESA therapy 2, 1