Official reprint from UpToDate®
www.uptodate.com ©2018 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Treatment of anemia in hemodialysis patients

Jeffrey S Berns, MD
Section Editors
Steve J Schwab, MD
Gary C Curhan, MD, ScD
Deputy Editor
Alice M Sheridan, MD


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 [5]. (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.)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Dec 2017. | This topic last updated: Dec 08, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2018 UpToDate, Inc.
  1. Ma JZ, Ebben J, Xia H, Collins AJ. Hematocrit level and associated mortality in hemodialysis patients. J Am Soc Nephrol 1999; 10:610.
  2. Xia H, Ebben J, Ma JZ, Collins AJ. Hematocrit levels and hospitalization risks in hemodialysis patients. J Am Soc Nephrol 1999; 10:1309.
  3. Collins AJ, Li S, St Peter W, et al. Death, hospitalization, and economic associations among incident hemodialysis patients with hematocrit values of 36 to 39%. J Am Soc Nephrol 2001; 12:2465.
  4. Collins AJ, Ma JZ, Ebben J. Impact of hematocrit on morbidity and mortality. Semin Nephrol 2000; 20:345.
  5. World Health Organization. Nutritional Anaemias: Report of a WHO Scientific Group. Geneva, Switzerland: World Health Organization, 1968.
  6. http://www.kdigo.org/clinical_practice_guidelines/pdf/KDIGO-Anemia%20GL.pdf (Accessed on May 12, 2016).
  7. Chapter 1: Diagnosis and evaluation of anemia in CKD. Kidney Int Suppl (2011) 2012; 2:288.
  8. Besarab A, Bolton WK, Browne JK, et al. The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoetin. N Engl J Med 1998; 339:584.
  9. Besarab A, Goodkin DA, Nissenson AR, Normal Hematocrit Cardiac Trial Authors. The normal hematocrit study--follow-up. N Engl J Med 2008; 358:433.
  10. Zehnder C, Zuber M, Sulzer M, et al. Influence of long-term amelioration of anemia and blood pressure control on left ventricular hypertrophy in hemodialyzed patients. Nephron 1992; 61:21.
  11. Levin NW, Lazarus JM, Nissenson AR. National Cooperative rHu Erythropoietin Study in patients with chronic renal failure--an interim report. The National Cooperative rHu Erythropoietin Study Group. Am J Kidney Dis 1993; 22:3.
  12. Benz RL, Pressman MR, Hovick ET, Peterson DD. A preliminary study of the effects of correction of anemia with recombinant human erythropoietin therapy on sleep, sleep disorders, and daytime sleepiness in hemodialysis patients (The SLEEPO study). Am J Kidney Dis 1999; 34:1089.
  13. Parfrey PS, Lauve M, Latremouille-Viau D, Lefebvre P. Erythropoietin therapy and left ventricular mass index in CKD and ESRD patients: a meta-analysis. Clin J Am Soc Nephrol 2009; 4:755.
  14. Association between recombinant human erythropoietin and quality of life and exercise capacity of patients receiving haemodialysis. Canadian Erythropoietin Study Group. BMJ 1990; 300:573.
  15. Beusterien KM, Nissenson AR, Port FK, et al. The effects of recombinant human erythropoietin on functional health and well-being in chronic dialysis patients. J Am Soc Nephrol 1996; 7:763.
  16. NKF-DOQI Clinical Practice Guidelines for Anemia of Chronic Renal Failure. Am J Kidney Dis 2006; 47(Suppl 4):S1.
  17. Kaufman JS, Reda DJ, Fye CL, et al. Subcutaneous compared with intravenous epoetin in patients receiving hemodialysis. Department of Veterans Affairs Cooperative Study Group on Erythropoietin in Hemodialysis Patients. N Engl J Med 1998; 339:578.
  18. Locatelli F, Canaud B, Giacardy F, et al. Treatment of anaemia in dialysis patients with unit dosing of darbepoetin alfa at a reduced dose frequency relative to recombinant human erythropoietin (rHuEpo). Nephrol Dial Transplant 2003; 18:362.
  19. Nissenson AR, Swan SK, Lindberg JS, et al. Randomized, controlled trial of darbepoetin alfa for the treatment of anemia in hemodialysis patients. Am J Kidney Dis 2002; 40:110.
  20. Tolman C, Richardson D, Bartlett C, Will E. Structured conversion from thrice weekly to weekly erythropoietic regimens using a computerized decision-support system: a randomized clinical study. J Am Soc Nephrol 2005; 16:1463.
  21. Weiner DE, Miskulin DC, Seefeld K, et al. Reducing versus discontinuing erythropoietin at high hemoglobin levels. J Am Soc Nephrol 2007; 18:3184.
  22. Wright DG, Wright EC, Narva AS, et al. Association of Erythropoietin Dose and Route of Administration with Clinical Outcomes for Patients on Hemodialysis in the United States. Clin J Am Soc Nephrol 2015; 10:1822.
  23. Pisoni RL, Bragg-Gresham JL, Young EW, et al. Anemia management and outcomes from 12 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2004; 44:94.
  24. Macdougall IC. Antibody-mediated pure red cell aplasia (PRCA): epidemiology, immunogenicity and risks. Nephrol Dial Transplant 2005; 20 Suppl 4:iv9.
  25. Rossert J, Casadevall N, Eckardt KU. Anti-erythropoietin antibodies and pure red cell aplasia. J Am Soc Nephrol 2004; 15:398.
  26. Bennett CL, Luminari S, Nissenson AR, et al. Pure red-cell aplasia and epoetin therapy. N Engl J Med 2004; 351:1403.
  27. Boven K, Stryker S, Knight J, et al. The increased incidence of pure red cell aplasia with an Eprex formulation in uncoated rubber stopper syringes. Kidney Int 2005; 67:2346.
  28. KDOQI. KDOQI Clinical Practice Guideline and Clinical Practice Recommendations for anemia in chronic kidney disease: 2007 update of hemoglobin target. Am J Kidney Dis 2007; 50:471.
  29. Berns JS, Elzein H, Lynn RI, et al. Hemoglobin variability in epoetin-treated hemodialysis patients. Kidney Int 2003; 64:1514.
  30. Lacson E Jr, Ofsthun N, Lazarus JM. Effect of variability in anemia management on hemoglobin outcomes in ESRD. Am J Kidney Dis 2003; 41:111.
  31. Fishbane S, Berns JS. Hemoglobin cycling in hemodialysis patients treated with recombinant human erythropoietin. Kidney Int 2005; 68:1337.
  32. Locatelli F, de Francisco A, Deray G, et al. Mortality and cardiovascular morbidity associated with haemoglobin levels: a pooled analysis of randomised controlled trials. Nephron Clin Pract 2014; 128:323.
  33. http://www.fda.gov/Drugs/DrugSafety/ucm259639.htm (Accessed on July 28, 2011).
  34. Strippoli GF, Craig JC, Manno C, Schena FP. Hemoglobin targets for the anemia of chronic kidney disease: a meta-analysis of randomized, controlled trials. J Am Soc Nephrol 2004; 15:3154.
  35. Volkova N, Arab L. Evidence-based systematic literature review of hemoglobin/hematocrit and all-cause mortality in dialysis patients. Am J Kidney Dis 2006; 47:24.
  36. Parfrey PS. Target hemoglobin level for EPO therapy in CKD. Am J Kidney Dis 2006; 47:171.
  37. Phrommintikul A, Haas SJ, Elsik M, Krum H. Mortality and target haemoglobin concentrations in anaemic patients with chronic kidney disease treated with erythropoietin: a meta-analysis. Lancet 2007; 369:381.
  38. Pfeffer MA, Burdmann EA, Chen CY, et al. A trial of darbepoetin alfa in type 2 diabetes and chronic kidney disease. N Engl J Med 2009; 361:2019.
  39. Palmer SC, Navaneethan SD, Craig JC, et al. Meta-analysis: erythropoiesis-stimulating agents in patients with chronic kidney disease. Ann Intern Med 2010; 153:23.
  40. Clement FM, Klarenbach S, Tonelli M, et al. The impact of selecting a high hemoglobin target level on health-related quality of life for patients with chronic kidney disease: a systematic review and meta-analysis. Arch Intern Med 2009; 169:1104.
  41. Coyne DW. The health-related quality of life was not improved by targeting higher hemoglobin in the Normal Hematocrit Trial. Kidney Int 2012; 82:235.
  42. Collister D, Komenda P, Hiebert B, et al. The Effect of Erythropoietin-Stimulating Agents on Health-Related Quality of Life in Anemia of Chronic Kidney Disease: A Systematic Review and Meta-analysis. Ann Intern Med 2016; 164:472.
  43. Singh AK, Szczech L, Tang KL, et al. Correction of anemia with epoetin alfa in chronic kidney disease. N Engl J Med 2006; 355:2085.
  44. Churchill DN, Muirhead N, Goldstein M, et al. Probability of thrombosis of vascular access among hemodialysis patients treated with recombinant human erythropoietin. J Am Soc Nephrol 1994; 4:1809.
  45. Parfrey PS, Foley RN, Wittreich BH, et al. Double-blind comparison of full and partial anemia correction in incident hemodialysis patients without symptomatic heart disease. J Am Soc Nephrol 2005; 16:2180.
  46. Vaziri ND. Mechanism of erythropoietin-induced hypertension. Am J Kidney Dis 1999; 33:821.
  47. Drüeke TB, Locatelli F, Clyne N, et al. Normalization of hemoglobin level in patients with chronic kidney disease and anemia. N Engl J Med 2006; 355:2071.
  48. Berns JS, Rudnick MR, Cohen RM, et al. Effects of normal hematocrit on ambulatory blood pressure in epoetin-treated hemodialysis patients with cardiac disease. Kidney Int 1999; 56:253.
  49. Beccari M. Seizures in dialysis patients treated with recombinant erythropoietin. Review of the literature and guidelines for prevention. Int J Artif Organs 1994; 17:5.
  50. Edmunds ME, Walls J, Tucker B, et al. Seizures in haemodialysis patients treated with recombinant human erythropoietin. Nephrol Dial Transplant 1989; 4:1065.