Anaemia in Renal Disease

Anaemia in CKD

Anaemia is a common complication of chronic kidney disease (CKD) and is associated with adverse outcomes. Investigation of anaemia for adults with CKD is recommended when haemoglobin falls below 11g/L, or when symptoms attributable to anaemia develop. EPO-replacement therapy with an erythropoiesis-stimulating agent (ESA) can be instigated for patients with CKD who have had other causes of anaemia investigated and excluded.

For further information on the possible causes of anaemia in renal disease and suggested baseline investigations, click here. To download the Renal Association Clinical Practice Guideline (2017) on Anaemia of Chronic Kidney Disease, please click here.

Iron Deficiency and Replacement

Patients with CKD should be iron-replete to achieve and maintain a target haemoglobin, irrespective of whether or not they are receiving ESAs. Assessing iron status is therefore mandatory. Doing so, however, is difficult and there is not a single fool-proof method. A ferritin of < 50μg/l is unequivocally diagnostic of iron deficiency, and <100μg/l is very likely to also. However, ferritin is an acute phase protein, and therefore higher levels may be found despite a functional iron deficiency. Transferrin saturation (TSAT) is a measure of the ability to mobilise stored iron for red cell production. TSAT < 20% is indicative of a functional iron deficiency, even if the ferritin levels are adequate. This may respond to treatment with IV iron.

Iron replacement therapy for patients with CKD can be oral or intravenous. The choice between these routes largely depends upon the severity of iron deficiency, previous response to treatment, and tolerability of oral iron supplements. Many patients with CKD and iron-deficiency will maintain their haemoglobin with oral iron supplements in the early stages, even those who begin peritoneal dialysis may continue to do well with oral therapy. However, the absorption of oral preparations of iron often becomes insufficient as CKD advances, and therefore treatment with IV iron becomes increasingly necessary. Oral iron supplements should be stopped with IV iron is commenced.

All patients on haemodialysis who are identified as being iron deficient will receive IV iron; this treatment is usually given on an on going basis rather than intermittently. In NHS Lothian Renal Department, we no longer routinely give test doses for IV iron as reactions, although serious, are rare. 

Diafer is the IV iron preparation of choice for haemodialysis patients within NHS Lothian. Dosing is patient dependent, but most patients will receive 100mg on a weekly, fortnightly, or monthly basis. Iron stores are checked once every 4 months, although more frequent testing may be indicated after dose adjustment.

For conservative care patients and those on peritoneal dialysis, Monofer is the preferred preparation where IV iron is required.

Erythropoesis-Stimulating Agents

In their 2017 clinical practice guideline, the Renal Association recommend that Erythropoiesis-Stimulating Agents (ESAs) should be offered to patients with anaemia of CKD who are likely to benefit in term of quality of life and physical function and to avoid blood transfusion; especially in patients considered suitable for transplantation. The recommended target haemoglobin for adult patients receiving ESAs is between 100 and 120g/L.

For patients receiving hospital-based haemodialysis therapy within NHS Lothian, ESAs are prescribed, dispensed and administered by the hospital under the supervision of a consultant nephrologist. This treatment is usually given intravenously during the haemodialysis session. Community-based patients, such as those with advanced CKD, pre-dialysis patients and those on peritoneal dialysis, can receive ESAs from the hospital or their GP via a shared-care agreement. This type of ESA therapy is usually given subcutaneously.

Quick Reference Guide for ESA therapy

This is a quick reference guide, to download the full ESA protocol click here (PDF download)

Indication Haemoglobin consistently below 110 g/l in a patient with CKD
Contra-indications Uncontrolled hypertension (SBP >190mmHg, DBP >90mmHg)
Baseline Investigations
  • • Exclude occult blood loss
  • • FBC and reticulocyte count
  • • Iron studies
  • • Vitamin B12 and Folate
  • • Dialysis adequacy
  • • PTH, CRP & TFTs
Initiation / Dosing Haemodialysis: 
• Neorecoromon
• 150 units/kg body weight/week
• Usually administered as 3 divided doses
• Given intravenously during dialysisPeritoneal dialysis, conservative care or pre-HD:
• Mircera
• 100 units/kg body weight/week as 2 divided doses
• Subcutaneously injection
Target Hb (g/l) • Population target Hb range: 100 – 120 g/l
• Hb should not be allowed to rise above 140g/l
Monitoring Haemoglobin should be checked every 2 weeks following initiation of an ESA, or after any dose alteration. Once stable haemoglobin is achieved, reduce monitoring to once every 4 weeks. 
Dose Adjustment Induction period (Hb <11g/dl ):
– If the rate of rise is <10 g/l/month, increase weekly ESA dose by 25%
– If the rate of rise of Hb is ≥ 15 g/l/month, decrease weekly dose by 25-50%Stable period (Hb >10 g/dl)
– If Hb exceeds 125g/l, reduce weekly dose by 25-50% and consider period of discontinuation
– If Hb falls below 100g/l, increase weekly dose by 25-50%
Discontinuation If ESA therapy is discontinued because of a sharp rise in haemoglobin, bloods should be monitored and ESA recommenced at a lower dose 2 weeks after discontinuation.
Resistance If ESA doses ≥250units/kg/week are required to maintain Hb, this should be discussed with senior staff and patients should be investigated for causes of ESA resistance






Blood Transfusions

Blood transfusions should be avoided as far as possible in patients who are on, or who in the future may be on, the transplant list. All blood products given to patients with renal disease who may be future transplant candidates should be treated to remove white blood cells. Our Blood Transfusion Service now routinely provides leucocyte-depleted products for all patients. When blood transfusion is felt to be necessary for renal patients, careful consideration should be given to volume status. If blood is being given on haemodialysis, each unit is usually given over 1 hour and the equivalent fluid volume removed by ultrafiltration.

Education / Resources

Acknowledgements: John Webster and Sue Mann were the original authors for this page, revised by Paddy Gibson and Wendy King. This page was reviewed and updated by Ashley Simpson in 2019. The date it was last modified is shown in the footer.

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