Diagnosing and Treating Anemia of Kidney Disease

Kidney disease causes anemia; here's how you could treat it

Andrew Mason; Flickr.com; Creative Commons 2.0 License

Anemia, or low red cell/hemoglobin count is a common problem in Chronic Kidney Disease (CKD). Severity of anemia worsens with the severity of kidney disease. Hence anemia is present in a far greater proportion of patients in stage 4 or 5 kidney disease, as opposed to stage 3 disease. According to data, prevalence of anemia is strongly associated with declining glomerular filtration rate (GFR). Anemia of chronic kidney disease commonly causes symptoms ranging from shortness of breath, decreased appetite, to congestive heart failure and death in worst cases.

The reason anemia develops in patients with kidney disease are many- the main ones being chronic inflammation and deficiency of a hormone essential to red cell production- erythropoietin.

The severity of symptoms of anemia of kidney disease, and the increased risk of death make diagnosis and treatment necessary. The knowledge of how this specific anemia develops, thankfully, makes treatment possible. 


Just because someone has kidney disease does not necessarily mean that their anemia is due to kidney disease.  Other causes of anemia still need to be ruled out.  Patients could still have the good old iron deficiency.  Blood loss as the cause of anemia is entirely possible.  This is most often seemed as a slow insidious finding where patients bleed into the gut.  In fact kidney disease might increase the risk of bleeding because of multiple factors.

Diagnosis of anemia in patients with kidney disease starts with a thorough history and physical exam, followed by blood work. Your physician might order the following tests:

  • A complete blood count with microscopy exam
  • Assessment of your iron stores
  • Vitamin B12 and Folate levels
  • Tests to look for signs of red blood cell destruction
  • Tests to rule out chronic bleeding (some patients might need invasive procedures like a colonoscopy)

​After going through these tests, your nephrologist should be able to diagnose if your anemia is related to the kidney disease.  Quite often, the picture is not very simplistic.  Multiple factors might lead to anemia in one patient.  For instance, a patient with anemia of chronic kidney disease could also have coexisting iron deficiency or blood loss going on.  All these causes will need to be specifically dealt with for optimal treatment.

As per KDIGO, anemia in patients with kidney disease is defined as hemoglobin less than 13 for adult males and less than 12 for adult females.


As mentioned above, anemia, even in patients with kidney disease could be multifactorial.  If I see a patient with this background, my first goal is to start with the least aggressive options and replete any nutritional deficiencies that might be present.  Therefore starting with simple measures like iron supplementation might suffice.

The next step could involve supplementing erythropoietin with erythropoietin stimulating agents (ESAs) to make up for the lack of production coming from diseased kidneys. ESAs are only indicated for significant anemia in the right candidate patient, usually for a hemoglobin level of less than 10.

For patients who are not on dialysis, the medication is often given as a subcutaneous injection once every 1-2 weeks.  Dialysis patients will often receive this as part of their dialytic treatment intravenously.


Replacing erythropoietin stimulating agents is analogous to replacing insulin in a diabetic.  Basically you are deficient in an essential hormone, so you replace it with a synthetic alternative.  However ESAs are drugs that are to be taken with utmost caution.  The are extremely efficacious in increasing hemoglobin levels and sometimes improving the quality-of-life and symptoms in the ideal patient. However inappropriate use can lead to serious side effects including worsening of high blood pressure, heart attacks, strokes, and blood clots.  More is not always better when it comes to hemoglobin levels that are jacked up by use of erythropoietin stimulating agents.  There have been major studies that have shown that patients treated to too high levels of hemoglobin because of use of these agents actually do worse and have a higher risk of death.

Continue Reading