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Anemia Management in CKD

Definition of Anemia in CKD

EPO Deficiency
Functional Iron Deficiency (have adequate iron stores but iron cannot be mobilized)
Absolute Iron Deficiency

Every visit in patients with CKD stages 3-5
Monthly if on KRT
Check CBC with diff, reticulocyte count, serum iron, serum ferritin, TSAT, in select patients, can check B12 and folate if at risk for deficiency

If patient already on iron and ESA and not responding or anemia seems out of proportion to their CKD, will need further investigation, such as colonoscopy, workup of possible bone marrow malignancy and potentially hematology referral
If iron deficient assess for causes of Iron deficiency, ask about GI losses and diet

Adult patient with CKD not on dialysis:
Hemoglobin >10 g/dL do not initiate EPO, can check iron studies and replete if iron deficient, rule out other causes of anemia
If hemoglobin <10 g/dL can consider ESA, and treat iron deficiency if deficient. If TSAT ≤30 percent and/or a serum ferritin concentration ≤500 ng/mL, start on iron.
Start ESAs if hemoglobin <10 g/dL if iron deficient and did not respond to iron supplementation alone

KDIGO Clinical guidelines for the use of iron to treat iron deficiency anemia
Patient Population	Threshold for therapy	Recommended Therapy
CKD with anemia not on ESA or Iron	An increase in Hgb concentration without starting ESA desired TSAT is </30% and ferritin is </500ng/mL	Trial of IV iron in patients on KRT If not on KRT can try oral iron for 1-3 months, if ineffective or side effects can try IV iron
CKD with anemia on ESA but not Iron	An increase in hemoglobin concentration or decrease in ESA dose is desired TSAT is </30% and ferritin is </500 ng/mL

Daily dosing– Daily administration with goal elemental irοn intake of approximately 200 mg per day in up to three divided doses. Recommended by KDIGO. Can use ferrous sulfate 325mg, which is 65mg of elemental iron, three times daily.
Alternate-day dosing– Alternate-day administration with goal elemental irοո intake of approximately 65 mg per day in a single dose, some data showing better absorption and fewer side effects but studies not done in patients with CKD
Oral irοn should be administered between meals. Antacids may decrease efficacy, if on antacid recommend separating the antacid and iron supplement (i.e. one in AM and one in PM)
Fеrriϲ citrate and sucroferric oxyhydroxide are oral phosphate binders that may be useful for oral irοn supplementation in patients who also have hyperphosphatemia. They are very expensive.
Watch out for and be ready to treat constipation.

Severe irоn deficiency (TSAT <12 %)
Severe anеmiа (hemoglobin </7 g/dL) in asymptomatic patients
Side effects to oral iroո
Not responding to oral iron
There are other IV iron formulations aside from listing below. Main one to remember is ferric carboxymaltose as it causes hypophosphatemia (usually seen in non-CKD).

IV iron formulations	Elemental Iron (mg/ml)	Dosing	Side Effects
Ferrlecit (Sodium ferric gluconate)	62.5	125 mg for 8 doses	Flushing, HA, fever, chills, hypotension
Venofer (Iron sucrose)	20	100 mg for 10 doses	Flushing, HA, fever, chills, hypotension
Ferahame (Ferumoxytol)	39	510 mg; 2 doses 3 to 8 days apart	Flushing, HA, fever, chills, hypotension
INFed (Dextran)	50	25mg IV once, then wait 30min to ensure no reaction, if no reaction give remaining 975mg one time. Alternatively can use formula to calculate precise dose.	Test dose used. Can cause severe allergic reaction
*Ferrlecit or InFed (dextran) is preferred at duke. InFed is a one time dose but can cause severe allergic reactions. Ferrlecit is over 8 doses but less likely to cause a reaction.

Micera (methoxy polyethylene glycol-epoetin beta) is the longest acting, Darbapoetin is longer acting than Epoetin
Avoid use of ЕЅAѕ in patients with active malignancy if possible due to increase in the risk of progression or recurrence of cancer.
Avoid EЅAѕ in patients with history of stroke since they may be at a higher risk for adverse effects (eg, recurrent stroke) from ЕЅΑs.
Increased risk of blood clots with ESA.
EPO resistance if failure to achieve a hemoglobin >11 g/dL despite an epoetin dose >300-450 units/kg/week or the equivalent of another ESA. Investigate for other causes of anemia if a patient has EPO resistance. Ensure the patient is iron replete.

ESA formulation	Dosing
Darbapoetin	IV or SubQ 0.45mcg/kg every 2-4 weeks.
Micera (Methoxy polyethylene glycol-epoetin beta)	Subq 0.6mcg/kg every 2 weeks or 1.2mcg/kg monthly IV 0.6mcg/kg every 2 weeks
Epoetin	IV or Subq 50-100U/kg every 1-2 weeks
*Only Epoetin and darbepoetin are available to order at the Duke infusion center.

Edited by Aruna Phekoo and Matthew A. Sparks Aug 12, 2025