Anemia of Chronic Kidney Disease

Book
In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan.
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Excerpt

Anemia is generally defined as a hemoglobin level of less than 13 g/dL in men and less than 12 g/dL in women. Anemia of chronic renal disease, also known as anemia of chronic kidney disease (CKD), is a type of normocytic and normochromic anemia and hypoproliferative anemia, which is common in patients with renal disease. Among other complications of CKD, it is frequently associated with poor outcomes, decreased quality of life, and increased mortality.

In 1836, anemia was first linked to renal disease by Richard Bright, also known as the "Father of Nephrology." As kidney disease progresses, the prevalence of anemia increases, affecting almost all patients with stage 5 CKD. The primary mechanisms behind anemia of CKD, including end-stage renal disease (ESRD), involve decreased erythropoietin production, decreased gastrointestinal iron absorption due to chronic inflammation, and a decreased lifespan of red blood cells (RBCs).

The treatment of anemia of CKD has advanced considerably in the last 2 decades. Before the therapeutic options currently available, the mainstay of treatment was blood transfusion, which came with numerous complications, including infections, hemosiderosis, fluid overload, and transfusion reactions. In addition, frequent blood transfusions increase the risk of allosensitization, which can worsen renal transplant outcomes if a transplant is an option.

In the 1970s, androgens were used to avoid transfusion in patients with CKD; however, this practice is now strongly discouraged. In the late 1980s, the development of recombinant erythropoietin, followed by erythropoiesis-stimulating agents (ESAs), revolutionized the management of anemia of CKD. Initially introduced to avoid transfusions, these treatments were soon found to have various positive effects, including improved survival and quality of life, improved cardiac function, reduced hospitalizations, and lower overall costs.

The mean hemoglobin level of dialysis patients increased from 9.6 g/dL in 1991 to 12.5 g/dL in 2005, and transfusion requirements decreased considerably. However, in 1998, the Normal Hematocrocrit Trial raised concerns about adverse events associated with higher hemoglobin or hematocrit goals. Subsequently, multiple trials have assessed the benefits of targeting higher versus lower hemoglobin ranges. The discovery of adverse effects of ESAs raised questions about their overall benefits and led to increased interest in finding alternative management strategies for anemia of CKD.

Anemia of CKD is highly associated with adverse outcomes such as cardiovascular events and increased mortality. Additionally, the severity of anemia correlates with decreased quality of life and increased hospitalizations. Understanding the diverse mechanisms involved, recommended treatment guidelines, and new therapeutic developments is crucial for managing this condition effectively.

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