Anemia Diagnosis and Treatment

Diagnostic Approach

The American Society of Nephrology and other guideline societies recommend beginning with a complete blood count (CBC) with red cell indices, reticulocyte count, iron studies, and inflammatory markers as essential first-line tests 1, 2
Anemia is defined as hemoglobin < 13 g/dL in men, < 12 g/dL in non-pregnant women, and < 11 g/dL in pregnant women, according to the National Comprehensive Cancer Network 1, 2

Microcytic anemia (MCV < 80 fL) most commonly indicates iron deficiency anemia, but also consider thalassemia, anemia of chronic disease, or sideroblastic anemia, as suggested by the Journal of the National Comprehensive Cancer Network 3, 1
Confirm iron deficiency with serum ferritin < 30 μg/L and transferrin saturation < 15%, based on guidelines from the Journal of the National Comprehensive Cancer Network and Praxis Medical Insights 3, 1

The American College of Physicians recommends oral iron supplementation as first-line treatment for iron deficiency anemia, with parenteral iron reserved for patients who cannot tolerate or absorb oral preparations 2
For vitamin B12 deficiency, the Journal of the National Comprehensive Cancer Network suggests intramuscular or deep subcutaneous cyanocobalamin, with maintenance doses given monthly for life 3
Folate deficiency should be treated with oral folate supplementation, with caution to avoid masking B12 deficiency symptoms, as recommended by Praxis Medical Insights 1

The Journal of the American Society of Nephrology recommends monitoring hemoglobin at least every three months in patients with GFR < 30 mL/min/1.73 m², and initiating workup if hemoglobin < 12 g/dL in women or < 13 g/dL in men 4, 2
Treat identified iron deficiency first, and if anemia persists despite iron therapy, initiate erythropoietin or analogue therapy, as suggested by the Journal of the American Society of Nephrology and American Journal of Kidney Diseases 4, 5

Never assume anemia is "normal aging" in elderly patients—always investigate the cause, as recommended by Praxis Medical Insights 2
Watch for combined deficiencies, especially in elderly patients and those with inflammatory bowel disease, as suggested by Praxis Medical Insights 2
Measuring serum erythropoietin levels is usually not indicated in chronic kidney disease patients with normochromic, normocytic anemia, according to the American Journal of Kidney Diseases 5