Anemia Management in Chronic Kidney Disease

Initial Evaluation and Treatment

The KDIGO guidelines recommend addressing all correctable causes of anemia, including iron deficiency and inflammatory states, prior to initiation of ESA therapy, in patients with chronic kidney disease (CKD) 1, 2, 4
Initial laboratory evaluation should include complete blood count, absolute reticulocyte count, serum ferritin level, and serum vitamin B12 and folate levels, to assess iron status and identify underlying causes of anemia 4, 5
The American Journal of Kidney Diseases suggests that iron supplementation should be initiated when transferrin saturation (TSAT) is ≤30% and ferritin is ≤500 ng/mL, in adult CKD patients not on dialysis 2, 5

The Kidney International guidelines recommend IV iron as the preferred route of administration in adult CKD patients on hemodialysis, with a target TSAT of ≤30% and ferritin of ≤500 ng/mL 1, 2, 4
For adult CKD patients not on dialysis, IV iron or a 1-3 month trial of oral iron should be initiated when TSAT is ≤30% and ferritin is ≤500 ng/mL, with the goal of increasing hemoglobin levels 2, 5
The American Journal of Kidney Diseases recommends administering oral iron or IV iron in pediatric CKD patients when TSAT is ≤20% and ferritin is ≤100 ng/mL, to maintain optimal iron status 1, 2, 6

The Kidney International guidelines suggest that ESAs should only be considered after addressing iron deficiency and other correctable causes of anemia, in adult CKD patients not on dialysis 1, 3
ESA therapy should not be initiated if hemoglobin is ≥10.0 g/dL, and the decision to start ESA therapy should be individualized based on rate of hemoglobin decline, prior response to iron therapy, and risks related to ESA therapy 1, 2, 3
The American Journal of Kidney Diseases recommends targeting a hemoglobin level between 9.0-10.0 g/dL in adult CKD patients on dialysis, to avoid falling below 9.0 g/dL 1, 2, 3

When administering IV iron, patients should be monitored for 60 minutes after infusion, with resuscitative facilities and trained personnel available, to minimize the risk of adverse reactions 1, 2, 3
The Kidney International guidelines recommend evaluating iron status at least every 3 months during treatment, and more frequently when initiating therapy or when iron stores may become depleted 2, 3