Treatment of anemia in nondialysis chronic kidney disease
- 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
Anemia is common among patients with chronic kidney disease (CKD). Anemia underlies many of the symptoms associated with reduced kidney function and is associated with increased mortality and hospitalizations [1-4].
The screening and treatment of anemia in nondialysis CKD patients are discussed here. Our approach to screening and treating anemia among hemodialysis and peritoneal dialysis patients is discussed elsewhere. (See "Treatment of iron deficiency in hemodialysis patients" and "Treatment of anemia in peritoneal dialysis patients".)
The treatment of iron deficiency among nondialysis CKD patients, hemodialysis patients, and peritoneal dialysis patients is discussed elsewhere. (See "Treatment of iron deficiency in nondialysis chronic kidney disease (CKD) patients" and "Treatment of iron deficiency in hemodialysis patients" and "Treatment of iron deficiency in peritoneal dialysis patients".)
Anemia is defined by the World Health Organization (WHO) as a hemoglobin (Hb) concentration <13.0 g/dL for adult males and postmenopausal women and an Hb <12.0 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 CKD patients. Thus, even when adequately treated, many CKD patients will have anemia as defined above. This is because the treatment of anemia involves erythropoiesis-stimulating agents (ESAs); multiple studies have now shown that targeting a normal Hb with ESAs increases risks of adverse outcomes. (See 'Target hemoglobin value' below.)
- Ma JZ, Ebben J, Xia H, Collins AJ. Hematocrit level and associated mortality in hemodialysis patients. J Am Soc Nephrol 1999; 10:610.
- Xia H, Ebben J, Ma JZ, Collins AJ. Hematocrit levels and hospitalization risks in hemodialysis patients. J Am Soc Nephrol 1999; 10:1309.
- 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.
- Collins AJ, Ma JZ, Ebben J. Impact of hematocrit on morbidity and mortality. Semin Nephrol 2000; 20:345.
- World Health Organization. Nutritional Anaemias: Report of a WHO Scientific Group. Geneva, Switzerland: World Health Organization, 1968.
- Hsu CY. Epidemiology of anemia associated with chronic renal insufficiency. Curr Opin Nephrol Hypertens 2002; 11:337.
- Hsu CY, McCulloch CE, Curhan GC. Epidemiology of anemia associated with chronic renal insufficiency among adults in the United States: results from the Third National Health and Nutrition Examination Survey. J Am Soc Nephrol 2002; 13:504.
- Astor BC, Muntner P, Levin A, et al. Association of kidney function with anemia: the Third National Health and Nutrition Examination Survey (1988-1994). Arch Intern Med 2002; 162:1401.
- Chapter 1: Diagnosis and evaluation of anemia in CKD. Kidney Int Suppl (2011) 2012; 2:288.
- Kliger AS, Foley RN, Goldfarb DS, et al. KDOQI US commentary on the 2012 KDIGO Clinical Practice Guideline for Anemia in CKD. Am J Kidney Dis 2013; 62:849.
- Moist LM, Troyanov S, White CT, et al. Canadian Society of Nephrology commentary on the 2012 KDIGO Clinical Practice Guideline for Anemia in CKD. Am J Kidney Dis 2013; 62:860.
- 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.
- 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.
- Provenzano R, Garcia-Mayol L, Suchinda P, et al. Once-weekly epoetin alfa for treating the anemia of chronic kidney disease. Clin Nephrol 2004; 61:392.
- Piccoli A, Malagoli A, Komninos G, Pastori G. Subcutaneous epoetin-alpha every one, two, and three weeks in renal anemia. J Nephrol 2002; 15:565.
- Provenzano R, Bhaduri S, Singh AK, PROMPT Study Group. Extended epoetin alfa dosing as maintenance treatment for the anemia of chronic kidney disease: the PROMPT study. Clin Nephrol 2005; 64:113.
- Benz R, Schmidt R, Kelly K, Wolfson M. Epoetin alfa once every 2 weeks is effective for initiation of treatment of anemia of chronic kidney disease. Clin J Am Soc Nephrol 2007; 2:215.
- McGowan T, Vaccaro NM, Beaver JS, et al. Pharmacokinetic and pharmacodynamic profiles of extended dosing of epoetin alfa in anemic patients who have chronic kidney disease and are not on dialysis. Clin J Am Soc Nephrol 2008; 3:1006.
- Pergola PE, Gartenberg G, Fu M, et al. A randomized controlled study comparing once-weekly to every-2-week and every-4-week dosing of epoetin alfa in CKD patients with anemia. Clin J Am Soc Nephrol 2010; 5:598.
- Koulouridis I, Alfayez M, Trikalinos TA, et al. Dose of erythropoiesis-stimulating agents and adverse outcomes in CKD: a metaregression analysis. Am J Kidney Dis 2013; 61:44.
- http://www.fda.gov/Drugs/DrugSafety/ucm259639.htm (Accessed on July 28, 2011).
- 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.
- 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.
- 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.
- Jing Z, Wei-jie Y, Nan Z, et al. Hemoglobin targets for chronic kidney disease patients with anemia: a systematic review and meta-analysis. PLoS One 2012; 7:e43655.
- 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.
- Initial screening
- Continued monitoring
- - Patients without anemia
- - Patients with anemia but not on an ESA
- - Patients treated with an ESA
- - Patients treated with iron
- Erythropoiesis-stimulating agents
- - Indications and contraindications
- - Route of administration
- - Dosing
- - Target hemoglobin value
- - Adverse effects
- SUMMARY AND RECOMMENDATIONS