Anemia in Kidney Disease and Dialysis

What is anemia?

A person whose blood is low in red blood cells has anemia. Red blood cells carry oxygen (O2) to tissues and organs throughout the body and enable them to use the energy from food. Without oxygen, these tissues and organs-particularly the heart and brain-may not do their jobs as well as they should. For this reason, a person who has anemia may tire easily and look pale. Anemia may also contribute to heart problems.

Anemia is common in people with kidney disease. Healthy kidneys produce a hormone called erythropoietin, or EPO, which stimulates the bone marrow to produce the proper number of red blood cells needed to carry oxygen to vital organs. Diseased kidneys, however, often don't make enough EPO. As a result, the bone marrow makes fewer red blood cells. Other common causes of anemia include blood loss from hemodialysis and low levels of iron and folic acid. These nutrients from food help young red blood cells make hemoglobin, their main oxygen-carrying protein.

What are the laboratory tests for anemia?

A complete blood count (CBC), a laboratory test performed on a sample of blood, includes a determination of a person's hematocrit, the percentage of the blood that consists of red blood cells. The CBC also measures the amount of hemoglobin in the blood. The range of normal hematocrit and hemoglobin in women who have a period is slightly lower than for healthy men and healthy women who have stopped having periods (postmenopausal). The hemoglobin is usually about one-third the value of the hematocrit.

When does anemia begin?

Anemia may begin to develop in the early stages of kidney disease, when you still have 20 percent to 50 percent of your normal kidney function. This partial loss of kidney function is often called chronic renal insufficiency. Anemia tends to worsen as kidney disease progresses. End-stage kidney failure, the point at which dialysis or kidney transplantation becomes necessary, doesn't occur until you have only about 10 percent of your kidney function remaining. Nearly everyone with end-stage kidney failure has anemia.

How is anemia diagnosed?

If a person has lost at least half of normal kidney function and has a low hematocrit, the most likely cause of anemia is decreased EPO production. The estimate of kidney function, also called the glomerular filtration rate, is based on a blood test that measures creatinine. Experts recommend that doctors begin a detailed evaluation of anemia in men and postmenopausal women on dialysis when the hematocrit falls below 37 percent. For women of childbearing age, evaluation should begin when the hematocrit falls below 33 percent. The evaluation will include tests for iron deficiency and blood loss in the stool to be certain there are no other reasons for the anemia.

How is anemia treated?


If no other cause for anemia is found, it can be treated with a genetically engineered form of EPO. The EPO is usually injected under the skin two or three times a week. Patients on hemodialysis who can't tolerate EPO shots may receive the hormone intravenously during treatment. The intravenous method, however, requires a larger, more expensive dose and may not be as effective.

The U.S. Food and Drug Administration (FDA) recommends that patients treated with EPO therapy should achieve a target hemoglobin between 10 and 12 grams per deciliter (g/dL). Recent studies have shown that raising the hemoglobin above 12 g/dL in people who have kidney disease increases the risk of heart attack, heart failure, and stroke. People who take EPO shots should have regular tests to monitor their hemoglobin. If it climbs above 12 g/dL, their doctor should prescribe a lower dose of EPO. The FDA recommends that patients whose hemoglobin does not rise to the target level with normal doses of EPO ask their doctor to check for other causes of anemia.


Many people with kidney disease need both EPO and iron supplements to raise their hematocrit to a satisfactory level. If a person's iron levels are too low, EPO won't help and that person will continue to experience the effects of anemia. Some people are able to take an iron pill, but many studies show that iron pills don't work as well in people with kidney failure as iron given intravenously. Iron can be injected into an arm vein or into the tube that returns blood to the body during hemodialysis.

A nurse or doctor will give each patient a test dose because a small number of people-less than 1 percent-have a bad reaction to iron injections. If a patient begins to wheeze or have trouble breathing, the health care provider can give epinephrine or corticosteroids to counter the reaction. Even though the risk is small, patients are asked to sign a form stating they understand the possible reaction and they agree to have the treatment. Patients should talk with their health care providers if they have any questions.

In addition to measuring hematocrit and hemoglobin, the CBC test will include two other measurements to show whether a person has enough iron.

What are some other causes of anemia?

In addition to EPO and iron, a few people may need vitamin B12 and folic acid supplements.

If EPO, iron, vitamin B12, and folic acid supplements do not help, the doctor should look for other causes of anemia such as sickle cell disease or an inflammatory problem. At one time, aluminum poisoning contributed to anemia in people with kidney failure. Many phosphate binders used to treat bone disease caused by kidney failure were antacids that contained aluminum. But aluminum-free alternatives are now widely available. People with CKD and kidney failure should be sure their phosphate binder and other drugs are free of aluminum.

Anemia keeps many people with kidney disease from feeling their best. But EPO treatments help most patients raise their hemoglobin and have more energy.

Points to Remember