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Updated: Dec 16 2021

Anemia of Renal Failure

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  • 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
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