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Anemia of Renal Disease


Evan M. Braunstein

, MD, PhD, Johns Hopkins University School of Medicine

Last review/revision Sep 2021 | Modified Sep 2022
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Anemia of renal disease is a hypoproliferative anemia Overview of Decreased Erythropoiesis Anemia, a decrease in the number of red blood cells (RBCs), hemoglobin (Hb) content, or hematocrit (Hct), can result from decreased RBC production (erythropoiesis), increased RBC destruction... read more resulting primarily from deficient erythropoietin (EPO) or a diminished response to it; it tends to be normocytic and normochromic. Treatment includes measures to correct the underlying disorder and supplementation with EPO and sometimes iron.

Anemia in chronic renal disease is multifactorial.

The most common mechanism is

  • Hypoproliferation due to decreased erythropoietin (EPO) production

Other factors include

  • Blood loss due to dysfunctional platelets, dialysis, and/or angiodysplasia

  • Bone marrow resistance to EPO

  • Secondary hyperparathyroidism

  • Uremia (in which mild hemolysis is common due to an increase in red blood cell [RBC] deformity)

The deficiency in renal production of EPO and the severity of anemia do not always correlate with the extent of renal dysfunction; anemia occurs when creatinine clearance is < 45 mL/minute (< 0.75 mL/s/m2). Renal glomerular lesions (eg, due to amyloidosis Amyloidosis Amyloidosis is any of a group of disparate conditions characterized by extracellular deposition of insoluble fibrils composed of misaggregated proteins. These proteins may accumulate locally... read more Amyloidosis , diabetic nephropathy Diabetic Nephropathy Diabetic nephropathy is glomerular sclerosis and fibrosis caused by the metabolic and hemodynamic changes of diabetes mellitus. It manifests as slowly progressive albuminuria with worsening... read more Diabetic Nephropathy ) generally result in the most severe anemia for their degree of renal excretory failure.

General reference

  • 1. Kautz L, Jung G, Valore EV, et al: Identification of erythroferrone as an erythroid regulator of iron metabolism. Nat Genet 46:678–684, 2014. doi: 10.1038/ng.2996

Diagnosis of Anemia of Renal Disease

  • Complete blood count (CBC) and peripheral smear

Diagnosis of anemia of renal disease is based on demonstration of renal insufficiency, normocytic anemia, and peripheral reticulocytopenia.

The bone marrow may show erythroid hypoplasia. RBC fragmentation identified on the peripheral smear Peripheral smear Anemia is a decrease in the number of red blood cells (RBCs) as measured by the red cell count, the hematocrit, or the red cell hemoglobin content. In men, anemia is defined as any of the following... read more Peripheral smear , particularly if there is thrombocytopenia, suggests simultaneous traumatic hemolysis.

Treatment of Anemia of Renal Disease

  • Treatment of underlying renal disease

  • Sometimes, recombinant erythropoietin and iron supplements

Treatment of anemia of renal disease is directed at

  • Improving renal function

  • Increasing RBC production

If renal function returns to normal, anemia is slowly corrected.

Recombinant EPO has been shown to improve anemia and reduce transfusion needs in patients with chronic kidney disease. In patients receiving long-term dialysis, recombinant erythropoietin beginning with 50 to 100 units/kg IV or subcutaneously 3 times a week with iron supplements is the treatment of choice. However, because there is both reduced production of EPO and marrow resistance to EPO, the recombinant EPO dose may need to be 150 to 300 units/kg subcutaneously 3 times a week. The goal is a hemoglobin of 10 to 12 g/dL (100 to 120 g/L). Careful monitoring of hemoglobin response is needed because adverse effects (eg, venous thromboembolism Deep Venous Thrombosis (DVT) Deep venous thrombosis (DVT) is clotting of blood in a deep vein of an extremity (usually calf or thigh) or the pelvis. DVT is the primary cause of pulmonary embolism. DVT results from conditions... read more Deep Venous Thrombosis (DVT) , myocardial infarction Acute Myocardial Infarction (MI) Acute myocardial infarction is myocardial necrosis resulting from acute obstruction of a coronary artery. Symptoms include chest discomfort with or without dyspnea, nausea, and/or diaphoresis... read more Acute Myocardial Infarction (MI) , death) may occur when hemoglobin rises to > 12 g/dL (> 120 g/L).

In almost all cases, maximum increases in RBCs are reached by 8 to 12 weeks.

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