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Anaemia in Chronic Kidney Disease
Related Subjects: |Metabolic acidosis |Lactic acidosis |Acute Kidney Injury (AKI) / Acute Renal Failure |Renal/Kidney Physiology |Chronic Kidney Disease (CKD) |Anaemia in Chronic Kidney Disease |Analgesic Nephropathy |Medullary Sponge kidney |IgA Nephropathy (Berger's disease) |HIV associated nephropathy (HIVAN) |Balkan endemic nephropathy (BEN) |Autosomal Dominant Polycystic kidney disease
ℹ️ About
- A very common cause of anaemia, especially in advanced CKD (stages 3–5).
- Caused mainly by reduced renal erythropoietin (EPO) production → reduced red cell synthesis.
- Contributes to fatigue, reduced exercise tolerance, left ventricular hypertrophy, and poorer quality of life.
🧬 Aetiology
- ⬇️ EPO synthesis → impaired bone marrow red cell production.
- Uraemia → shortened red cell survival.
- Iron deficiency → due to reduced absorption, chronic inflammation, and dialysis/GI blood loss.
- Folate deficiency → may occur from dialysis-related losses.
🔎 Investigations
- FBC: Normocytic, normochromic anaemia; ↓ Hb; reticulocytes low/normal.
- Blood film: Echinocytes (“burr cells”).
- U&E: Raised urea/creatinine.
- eGFR: Anaemia more likely if GFR < 30 ml/min/1.73 m².
- Iron studies: Ferritin and transferrin saturation (note: ferritin = acute-phase reactant).
- CRP/ESR: May indicate chronic inflammation.
Additional Tests (exclude other causes)
- Vitamin B12 and folate levels.
- Haemolysis screen: haptoglobin, LDH, bilirubin, DAT.
- Serum/urine protein electrophoresis ± free light chains (exclude myeloma).
- Hb electrophoresis (exclude thalassaemia/haemoglobinopathy).
- Bone marrow biopsy if cytopenias unexplained.
💊 Management
- Correct reversible causes: Replace iron, folate, or B12 as needed. ➡️ IV iron often preferred in dialysis patients.
- Erythropoiesis-stimulating agents (ESAs):
- Epoetin alfa/beta: 50–100 units/kg IV/SC, 3× weekly (often with dialysis).
- Darbepoetin alfa: Longer half-life → weekly dosing.
- Peginesatide / Methoxy-PEG-Epoetin beta: Monthly dosing.
- Target Hb: 100–120 g/L. ⚠️ Avoid overcorrection (>130 g/L) → ↑ stroke & thrombotic risk.
- Optimise CKD care: control BP, manage bone–mineral disease, ensure adequate dialysis.
References
Clinical Pearl:
Anaemia of CKD = typically normocytic + hypoproliferative.
Always exclude iron, folate, or B12 deficiency before ESAs.
Over-correcting Hb can worsen cardiovascular outcomes.
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