Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Effects of anemia in chronic kidney disease

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


Anemia is common among patients with chronic kidney disease (CKD). In addition to causing disabling symptoms, severe anemia may affect cardiovascular function in nondialysis CKD and dialysis patients. Among nondialysis CKD patients, severe anemia may accelerate the progression to end-stage renal disease (ESRD).

This topic reviews the effects of anemia on cardiovascular dysfunction, particularly left ventricular hypertrophy (LVH) and heart failure (HF), and on the progression of kidney dysfunction in CKD patients.

Other signs and symptoms of anemia (which are the same in CKD patients as among individuals without kidney disease) are discussed elsewhere. (See "Approach to the adult patient with anemia", section on 'Clinical consequences' and "Anemia in the older adult", section on 'Functional outcomes'.)

The treatment of anemia among CKD patients is discussed elsewhere. (See "Treatment of anemia in nondialysis chronic kidney disease" and "Treatment of anemia in hemodialysis patients" and "Treatment of anemia in peritoneal dialysis patients".)


Cardiovascular disease is a major cause of morbidity and mortality in patients with CKD, including those undergoing maintenance dialysis [1]. Even patients with mild CKD have a greater burden of prevalent cardiovascular disease compared with similar age controls [2]. (See "Chronic kidney disease and coronary heart disease" and "Myocardial dysfunction in end-stage renal disease".)

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: Nov 2017. | This topic last updated: Dec 01, 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 ©2017 UpToDate, Inc.
  1. United States Renal Data System. USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institute of Health, National Institute of Diabetes, Digestive and Kidney Diseases, Bethesda, MD 2013.
  2. Go AS, Chertow GM, Fan D, et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004; 351:1296.
  3. Parfrey PS, Foley RN. The clinical epidemiology of cardiac disease in chronic renal failure. J Am Soc Nephrol 1999; 10:1606.
  4. McClellan WM, Flanders WD, Langston RD, et al. Anemia and renal insufficiency are independent risk factors for death among patients with congestive heart failure admitted to community hospitals: a population-based study. J Am Soc Nephrol 2002; 13:1928.
  5. Astor BC, Arnett DK, Brown A, Coresh J. Association of kidney function and hemoglobin with left ventricular morphology among African Americans: the Atherosclerosis Risk in Communities (ARIC) study. Am J Kidney Dis 2004; 43:836.
  6. Parfrey PS, Foley RN, Harnett JD, et al. Outcome and risk factors for left ventricular disorders in chronic uraemia. Nephrol Dial Transplant 1996; 11:1277.
  7. Paoletti E, Specchia C, Di Maio G, et al. The worsening of left ventricular hypertrophy is the strongest predictor of sudden cardiac death in haemodialysis patients: a 10 year survey. Nephrol Dial Transplant 2004; 19:1829.
  8. Stewart GA, Gansevoort RT, Mark PB, et al. Electrocardiographic abnormalities and uremic cardiomyopathy. Kidney Int 2005; 67:217.
  9. Middleton RJ, Parfrey PS, Foley RN. Left ventricular hypertrophy in the renal patient. J Am Soc Nephrol 2001; 12:1079.
  10. Harnett JD, Kent GM, Foley RN, Parfrey PS. Cardiac function and hematocrit level. Am J Kidney Dis 1995; 25:S3.
  11. Foley RN, Parfrey PS, Harnett JD, et al. The impact of anemia on cardiomyopathy, morbidity, and and mortality in end-stage renal disease. Am J Kidney Dis 1996; 28:53.
  12. Frank H, Heusser K, Höffken B, et al. Effect of erythropoietin on cardiovascular prognosis parameters in hemodialysis patients. Kidney Int 2004; 66:832.
  13. Silverberg DS, Wexler D, Blum M, et al. Erythropoietin should be part of congestive heart failure management. Kidney Int Suppl 2003; :S40.
  14. London GM. Left ventricular alterations and end-stage renal disease. Nephrol Dial Transplant 2002; 17 Suppl 1:29.
  15. Martinez-Vea A, Marcas L, Bardají A, et al. Role of oxidative stress in cardiovascular effects of anemia treatment with erythropoietin in predialysis patients with chronic kidney disease. Clin Nephrol 2012; 77:171.
  16. van der Meer P, Voors AA, Lipsic E, et al. Erythropoietin in cardiovascular diseases. Eur Heart J 2004; 25:285.
  17. van der Meer P, Lipsic E, Henning RH, et al. Erythropoietin improves left ventricular function and coronary flow in an experimental model of ischemia-reperfusion injury. Eur J Heart Fail 2004; 6:853.
  18. 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.
  19. Eckardt KU, Scherhag A, Macdougall IC, et al. Left ventricular geometry predicts cardiovascular outcomes associated with anemia correction in CKD. J Am Soc Nephrol 2009; 20:2651.
  20. Sanchis-Gomar F, Garcia-Gimenez JL, Pareja-Galeano H, et al. Erythropoietin and the heart: physiological effects and the therapeutic perspective. Int J Cardiol 2014; 171:116.
  21. Moon C, Krawczyk M, Ahn D, et al. Erythropoietin reduces myocardial infarction and left ventricular functional decline after coronary artery ligation in rats. Proc Natl Acad Sci U S A 2003; 100:11612.
  22. Parsa CJ, Kim J, Riel RU, et al. Cardioprotective effects of erythropoietin in the reperfused ischemic heart: a potential role for cardiac fibroblasts. J Biol Chem 2004; 279:20655.
  23. Parsa CJ, Matsumoto A, Kim J, et al. A novel protective effect of erythropoietin in the infarcted heart. J Clin Invest 2003; 112:999.
  24. Calvillo L, Latini R, Kajstura J, et al. Recombinant human erythropoietin protects the myocardium from ischemia-reperfusion injury and promotes beneficial remodeling. Proc Natl Acad Sci U S A 2003; 100:4802.
  25. Todica A, Zacherl MJ, Wang H, et al. In-vivo monitoring of erythropoietin treatment after myocardial infarction in mice with [⁶⁸Ga]Annexin A5 and [¹⁸F]FDG PET. J Nucl Cardiol 2014; 21:1191.
  26. Ali-Hassan-Sayegh S, Mirhosseini SJ, Tahernejad M, et al. Administration of erythropoietin in patients with myocardial infarction: does it make sense? An updated and comprehensive meta-analysis and systematic review. Cardiovasc Revasc Med 2015; 16:179.
  27. Silverberg DS, Wexler D, Sheps D, et al. The effect of correction of mild anemia in severe, resistant congestive heart failure using subcutaneous erythropoietin and intravenous iron: a randomized controlled study. J Am Coll Cardiol 2001; 37:1775.
  28. Silverberg DS, Wexler D, Blum M, et al. Aggressive therapy of congestive heart failure and associated chronic renal failure with medications and correction of anemia stops or slows the progression of both diseases. Perit Dial Int 2001; 21 Suppl 3:S236.
  29. Silverberg DS, Wexler D, Blum M, et al. The effect of correction of anaemia in diabetics and non-diabetics with severe resistant congestive heart failure and chronic renal failure by subcutaneous erythropoietin and intravenous iron. Nephrol Dial Transplant 2003; 18:141.
  30. Silverberg DS, Wexler D, Blum M, et al. The use of subcutaneous erythropoietin and intravenous iron for the treatment of the anemia of severe, resistant congestive heart failure improves cardiac and renal function and functional cardiac class, and markedly reduces hospitalizations. J Am Coll Cardiol 2000; 35:1737.
  31. Kotecha D, Ngo K, Walters JA, et al. Erythropoietin as a treatment of anemia in heart failure: systematic review of randomized trials. Am Heart J 2011; 161:822.
  32. Kang J, Park J, Lee JM, et al. The effects of erythropoiesis stimulating therapy for anemia in chronic heart failure: A meta-analysis of randomized clinical trials. Int J Cardiol 2016; 218:12.
  33. Weiner DE, Tighiouart H, Vlagopoulos PT, et al. Effects of anemia and left ventricular hypertrophy on cardiovascular disease in patients with chronic kidney disease. J Am Soc Nephrol 2005; 16:1803.
  34. Chang JM, Chen SC, Huang JC, et al. Anemia and left ventricular hypertrophy with renal function decline and cardiovascular events in chronic kidney disease. Am J Med Sci 2014; 347:183.
  35. Astor BC, Coresh J, Heiss G, et al. Kidney function and anemia as risk factors for coronary heart disease and mortality: the Atherosclerosis Risk in Communities (ARIC) Study. Am Heart J 2006; 151:492.
  36. Levin A, Djurdjev O, Duncan J, et al. Haemoglobin at time of referral prior to dialysis predicts survival: an association of haemoglobin with long-term outcomes. Nephrol Dial Transplant 2006; 21:370.
  37. Mohanram A, Zhang Z, Shahinfar S, et al. Anemia and end-stage renal disease in patients with type 2 diabetes and nephropathy. Kidney Int 2004; 66:1131.
  38. Chatterjee PK. Pleiotropic renal actions of erythropoietin. Lancet 2005; 365:1890.
  39. Chung SD, Huang KH, Liao CH, et al. Acute heart failure with elevated cardiac enzymes. Kidney Int 2007; 72:521.
  40. Geng XC, Hu ZP, Lian GY. Erythropoietin ameliorates renal interstitial fibrosis via the inhibition of fibrocyte accumulation. Mol Med Rep 2015; 11:3860.
  41. Bartnicki P, Kowalczyk M, Rysz J. The influence of the pleiotropic action of erythropoietin and its derivatives on nephroprotection. Med Sci Monit 2013; 19:599.
  42. Jungers P, Choukroun G, Oualim Z, et al. Beneficial influence of recombinant human erythropoietin therapy on the rate of progression of chronic renal failure in predialysis patients. Nephrol Dial Transplant 2001; 16:307.
  43. Gouva C, Nikolopoulos P, Ioannidis JP, Siamopoulos KC. Treating anemia early in renal failure patients slows the decline of renal function: a randomized controlled trial. Kidney Int 2004; 66:753.
  44. Rossert J, Levin A, Roger SD, et al. Effect of early correction of anemia on the progression of CKD. Am J Kidney Dis 2006; 47:738.
  45. 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.
  46. 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.
  47. 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.
  48. Inrig JK, Barnhart HX, Reddan D, et al. Effect of hemoglobin target on progression of kidney disease: a secondary analysis of the CHOIR (Correction of Hemoglobin and Outcomes in Renal Insufficiency) trial. Am J Kidney Dis 2012; 60:390.
  49. 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.
  50. Cody JD, Hodson EM. Recombinant human erythropoietin versus placebo or no treatment for the anaemia of chronic kidney disease in people not requiring dialysis. Cochrane Database Syst Rev 2016; :CD003266.