Snapshot A 60-year-old woman with a history of chronic kidney disease on dialysis and diabetic nephropathy presents for a routine visit. Routine labs reveal a marked anemia to hemoglobin of 8 g/dL. She feels generally very weak and easily fatigable. She is started on EPO with a goal of hemoglobin of 11 g/dL. Introduction Anemia of renal failure, or anemia of chronic kidney disease is a normochromic, normocytic anemia epidemiology Risk factors decreased glomerular filtration rate angiotensin receptor blockers ACE-inhibitors etiology Pathogenesis erythropoietin (EPO) is synthesized in the kidney EPO stimulates red blood cell (RBC) production in chronic kidney disease, there is decreased EPO production leads to apoptosis of erythroid progenitor cells leads to decreased reticulocyte count and RBC production other factors contributing to anemia in chronic kidney disease include uremic-induced inhibition of RBC production shortened half-life Presentation Symptoms of anemia, which typically occur if hemoglobin < 10 g/dL fatigue generalized weakness dyspnea lightheadedness studies Anemia hemoglobin < 13 g/dL in men hemoglobin < 12 g/dL in women ↓ Reticulocyte count ↓ Serum EPO May see normal or decreased iron levels Signs of kidney damage albuminuria electrolyte abnormalities ↓ glomerular filtration rate Differential Diagnosis Anemia of chronic disease Iron deficiency anemia Treatment Medical management erythropoiesis-stimulating agents: EPO and darbepoetin alfa for CKD without dialysis begin if hemoglobin < 10 g/dL for CKD with dialysis begin if hemoglobin < 9 g/dL target hemoglobin < 12 g/dL iron supplement avoid red cell transfusions when possible due to risks, especially for those who may undergo organ transplantation risk of allosensitization Complications Untreated anemia increases risk for cardiovascular events and progression of CKD For patients with CKD, maintaining hemoglobin of > 12 g/dL will increase risk of stroke, diabetes, and cardiovascular events