Background

• The prevalence of anemia increases as the GFR decreases

Workup

• Usually due to CKD
• Exclude and assess other causes as well:
  • CBC
  • RBC indices
  • Reticulocytes
  • Iron studies
  • Folate
  • Vitamin B12
  • Stool occult blood

Indications for Treatment

• In general, treatment is needed when the Hgb < 100
• Anemia is defined as less than 130 in men, and less than 120 in women

Treatment

Iron

• Treat with iron if they are iron deficient, before the administration of ESAs
• i.e. TSAT <25% and ferritin <200 ng/mL
• Usually is IV iron

ESAs

• Treat if the Hgb is less than 100, provided that iron is repleted**
• Route: subcutaneous preferred
  • 30% lower dose with subcut than IV administration
  • More convenient, allows for self-administration
• Dose: darbepoetin
  • 60 to 200 mcg subcut every 2 to 4 weeks
  • Use the lowest effective dose
  • Increased risk of mortality and CV events with higher ESA doses regardless of Hgb
• Target Hgb level for most people is 100 to 115
  • Individualize, there is no rigorous target
  • Targeting higher than 130 is associated with an increased risk of adverse outcomes
• Adverse events are common
  • Increased risk of CV events
  • Hypertension (independent of the Hgb)
  • HD access thrombosis (Hgb level related)
  • Higher rates of adverse events in history of stroke or malignancy
• Benefits consist of
  • Reduced need for transfusion
  • Improved QOL
  • Improved exercise tolerance and LVH