Guidelines for Management of Anemia
For diagnosis of CKD-related anemia, a blood smear will show normocytic normochromic red blood cells. In addition, a complete blood count, iron binding capacity, ferritin, serum iron, reticulocyte count, vitamin B]2, and folate are obtained; hemolysis, folate and vitamin Bl2 deficiency, and irondeficiency are very common causes for anemia of CKD and should be
excluded in diagnosis (Murphy, Bennett, & Jenkins, 2010). Many patients with CKD-related anemia
also have iron deficiency because they are in a pro-inflammatory state and thus unable to use iron stores adequately. Diagnosis of absolute iron deficiency is based on serum ferritin values lower than or equal to 500 ng/ml and transferrin saturation (TSAT) less than or equal to
30% (KDIGO, 2012). When the patient is believed to have CKD-related anemia, appropriate
diagnostics should be completed so findings can guide the next course of action. For example,
if a patient displays signs consistent with iron deficiency based on serum ferritin results and transferrin saturation, occult gastrointestinal malignancy should be excluded before initiation of iron therapy. When iron stores are replenished and Hgb is less than or equal to 10 g/dL, erythropoietin-stimulating agent (ESA) therapy may be initiated with frequent monitoring of iron
stores. Patients who have signs consistent with vitamin B]2 or folate deficiency also should be supplemented with B12 and folate before initiation of ESA therapy. If no signs of iron, B]2, or folate deficiency exist and the patient has Hgb less than or equal to 10 g/dL, ESA may be initiated immediately with frequent iron stores testing (Taliercio, 2010). In summary, treatment for anemia hould not be initiated before testing for underlying causes. When any identified causes are treated or eliminated and the patient continues to maintain Hgb less than or
equal to 10 g/dL, ESAs should be used to maintain Hgb at 11.5 g/dl. Erythropoietin-stimulating agents should not be used intentionally to increase Hgb levels to greater than 13 g/dl (KDIGO, 2012)