Anaemia in CKD


A quick update in interpreting blood tests


In CKD stages 1,2 and 3a, anaemia is not solely due to EPO loss

Why do they become anaemic

HD patients have normal EPO levels but need higher levels to maintain Hb, hence they are commonly anaemic.

EPO replacement

  • When to start?   Hb< 10, symptomatic. Aim for Hb 10-12
  • Why is there a poor response?



  • Adverse effects of high levels of EPO
  1. Hypertension (Increased RAS activation)
  2. Vascular remodeling (Angiogenesis, VSMC proliferation)
  3. Proliferative retinopathy
  4. Tumour genesis
  5. Thrombosis (Platelet activation)
  • TREAT study – EPO doubled stroke risk, VTE risk, increased in arterial thromboembolic events , increase in cancer related deaths


Iron replacement

  • When to start?  Ferritin < 100, hypochromic red cells < 10%, TSAT > 20%
  • Give IV iron. Why?
    • Poor absorption in dialysis patients
    • State of inflammation up regulates hepcidin levels –> iron trapping within macrophages and liver cells and decreased gut iron absorption
    • GI adverse effects
  • Adverse effects? Unknown. Await PIVOTAL trial (in the UK)
  • So far, iron appears to be safe in increasing Hb in patients with no side effects seen


The Future?

Hypoxia Inducible Factor (HIF) stabilisers

  • Mimicking high altitude
  • HIF is activated under hypoxic situations
  • HIF stabilisers inhibit the enzyme that breaks down HIF
  • Increases patients EPO level
  • Undergoing trials