Management of Anemia in Patients with Chronic Kidney Disease and Rheumatoid Arthritis

Prevalence and Impact of Anemia

Anemia is highly prevalent in patients with chronic kidney disease (CKD), affecting 21-62% of non-dialysis CKD patients, with prevalence increasing in more advanced stages of kidney disease 1, 2
Anemia in chronic disease is associated with increased risk of hospitalizations, cardiovascular disease, cognitive impairment, and mortality in CKD patients 1, 2

Complete blood count is essential, with hemoglobin being the preferred measure over hematocrit due to better reproducibility across laboratories 3
Evaluation should include assessment of iron status with serum ferritin and transferrin saturation 3
Reticulocyte count helps evaluate the bone marrow response to anemia 3
In CKD patients, anemia is defined as hemoglobin <12 g/dL in females and <13.5 g/dL in males 1, 2

Optimizing treatment of the underlying chronic disease is the first and most important intervention for correcting anemia 5
For CKD patients on hemodialysis, proactive monthly administration of 400 mg intravenous iron in patients with serum ferritin <700 mg/L and TSAT <40% is recommended to decrease ESA use and lower mortality and cardiovascular events 1, 2
Iron therapy should precede ESA initiation to ensure adequate iron stores for effective erythropoiesis 6, 7
ESA therapy should be initiated when iron stores have been corrected, other reversible causes of anemia have been treated, and hemoglobin level is sustained below 100 g/L 6, 7
Target hemoglobin level should be 110 g/L, with an acceptable range of 100-120 g/L 6, 7

Iron deficiency is common in CKD and may be absolute or functional (due to inflammation/hepcidin-mediated iron sequestration) 1, 2, 4
Proactive IV iron administration in hemodialysis patients has been shown to decrease ESA requirements and improve cardiovascular outcomes 1, 2
ESAs should be used cautiously with a target hemoglobin of 110 g/L to avoid potential adverse effects 6, 7

Regular monitoring of hemoglobin levels is recommended, at minimum yearly for CKD patients 3
Periodic evaluation of iron parameters is necessary, with adjustments to treatment as needed 5

Avoid complete correction of anemia with ESAs as this may be associated with adverse outcomes 5
Be aware that iron administration may increase infection risk in susceptible patients 8, 9
Consider that the definitions of iron deficiency using current parameters (ferritin, TSAT) have limitations in chronic inflammatory states 4