Treatment of anemia in hemodialysis patients
- Jeffrey S Berns, MD
Jeffrey S Berns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Dialysis
- Professor of Medicine
- Perelman School of Medicine at the University of Pennsylvania
- Section Editors
- Steve J Schwab, MD
Steve J Schwab, MD
- Editor-in-Chief — Nephrology
- Section Editor — Dialysis
- University of Tennessee Health Science Center
- Gary C Curhan, MD, ScD
Gary C Curhan, MD, ScD
- Section Editor — Chronic Kidney Disease
- Professor of Medicine
- Harvard Medical School
Anemia is extremely common among hemodialysis patients and underlies some of the symptoms associated with reduced kidney function, including fatigue, depression, reduced exercise tolerance, and dyspnea. Anemia is also associated with increased morbidity and mortality related to cardiovascular disease and an increased risk of hospitalization and hospital length of stay [1-4].
Screening for and treating anemia is a routine part of the care of hemodialysis patients. This topic provides an approach to screening and treating anemia among such patients. The treatment of iron deficiency among hemodialysis patients is discussed elsewhere. (See "Treatment of iron deficiency in hemodialysis patients".)
The screening and treatment of anemia in nondialysis chronic kidney disease (CKD) patients and in peritoneal dialysis patients are discussed elsewhere. (See "Treatment of anemia in nondialysis chronic kidney disease" and "Treatment of anemia in peritoneal dialysis patients".)
Most nephrologists use the World Health Organization (WHO) criteria to define anemia. Anemia is defined by WHO as a hemoglobin (Hb) concentration <13 g/dL for adult males and postmenopausal women and an Hb <12 g/dL for premenopausal women . (See "Approach to the adult patient with anemia", section on 'Normal ranges for hemoglobin/HCT'.)
However, the WHO definition of anemia does not define goals of treatment among hemodialysis patients. Even when typically treated, hemodialysis patients will still have anemia as defined above. This is because, among hemodialysis patients, the treatment of anemia typically involves erythropoiesis-stimulating agents (ESAs) to avoid severe anemia and reduce the need for blood transfusions but not to normalize Hb levels. Multiple studies have shown that, among chronic kidney disease (CKD) patients (including those on hemodialysis), using ESAs to correct Hb to normal increases the risk of adverse outcomes. (See 'Treatment' below.)
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- Initial screening
- Continued monitoring
- INDICATIONS FOR TREATMENT
- Low hemoglobin <10 g/dL and transferrin saturation (TSAT) <30 percent and ferritin <500 ng/mL
- Hemoglobin >10 g/dL and TSAT <20 percent and ferritin <200 ng/mL
- Hemoglobin >10 g/dL and TSAT >20 percent and ferritin >200 ng/mL
- Low hemoglobin <10 g/dL and TSAT >30 percent
- Erythropoiesis-stimulating agents
- - Indications and contraindications
- - Dosing
- - Route of administration
- - Target levels
- - Adverse effects of erythropoiesis-stimulating agents
- SUMMARY AND RECOMMENDATIONS