Anemia Management in CKD

PPT ESA Ordering Guide for Epic

PPT IV Iron Ordering Guide for Epic

Definition of Anemia in CKD:

• <13 g/dL in males
• <12 g/dL in females

Causes of Anemia in CKD

• EPO Deficiency and resistance
• Iron restricted erythropoiesis (have adequate iron stores but iron cannot be mobilized, previously called functional iron deficiency)
• Other nutritional deficiencies (folate and B12)
• Systemic Iron Deficiency (previously absolute iron deficiency)
• Systemic inflammation
• Blood loss (dialysis, GI)
• Reduced RBC lifespan

Consequences of Anemia in CKD

• Increased mortality
• Decreased muscle mass
• Higher medical costs
• Cardiovascular disease, more LVH, heart failure
• Kidney disease progression
• Cognitive impairment
• Increased hospitalizations
• Increased transfusion requirement
• Reduced health-related quality of life

Management of Anemia in CKD not on KRT

Monitoring

• CKD G3: Screen at least annually
• CKD G4: Screen twice per year
• CKD G5 (non-dialysis): Screen every 3 months

Initial Evaluation

• CBC with differential
• Reticulocyte count
• Serum iron
• Ferritin
• TSAT
• Consider Vitamin B12 and folate in select patients

Severe Iron Deficiency (Ferritin <45 ng/mL)

• Evaluate for bleeding source (GI, urologic or gynecologic causes)

Iron Parameters (Ferritin ≤100 ng/mL AND TSAT ≤40% or Ferritin 100-300ng/mL AND TSAT ≤25%)

• PO iron OR IV iron based on patient’s values and preferences. Consider PO iron first in appropriate patients. For PO iron:
  • 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 were not done in patients with CKD.
  • PO 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 PO irοn supplementation in patients who also have hyperphosphatemia. They are very expensive.
  • Watch out for and be ready to treat constipation.
• Consider using Intravenous iron if
  • Inadequate response or intolerance to PO iron
  • Severe irоn deficiency (TSAT <12 %)
  • Severe anеmiа (hemoglobin </7 g/dL) in asymptomatic patient
  • Not responding to PO iron
  • There are other IV iron formulations aside from those listed below. Main one to remember is ferric carboxymaltose as it causes hypophosphatemia.
  • Monitor iron parameters every 3 months
  • Withhold iron if ferritin >700 ng/mL or TSAT ≥40%
  • Suspend iron therapy during active infection

PPT ESA Ordering Guide for Epic

• If not iron deficient, perform full anemia evaluation:
• Peripheral smear
• LDH, haptoglobin
• CRP
• Vitamin B12, folate
• Liver function tests
• Serum/urine protein electrophoresis
• TSH
• PTH
• Parasites (if indicated)

Consider ESA Therapy

• If no other correctable causes and Hb 9–10 g/dL

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ESAs

PPT ESA Ordering Guide for Epic

ESA Management

• Use lowest effective dose
• IV or subcutaneous route
• Micera is the longest acting, darbapoetin is longer acting than epoetin. Better to use micera or darbepoetin in clinic patients not on dialysis due to less frequent dosing.
• 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 because they may be at a higher risk for adverse effects (eg, recurrent stroke) from ЕЅΑs.
• Increased risk of blood clots with ESA.
• Monitor Hb every 2–4 weeks after initiation or dose change
• Do NOT maintain Hb >11.5 g/dL

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.

Excel document to convert between ESAs

ESA Hyporesponsiveness

• 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.
  • Evaluate for:
    • Iron deficiency
    • Inflammation
    • Infection
    • Hyperparathyroidism
    • Bleeding

HIF-PH Inhibitors

• Oral agents that stimulate endogenous EPO production
• Only approved for patients on dialysis
• HIF-PHI treatment can achieve comparable Hb levels to ESAs
  • Consider if ESA hyporesponsive or not tolerated, but guidelines recommend ESAs as preferred first-line therapy.
  • Preference for oral agent
  • No access to refrigeration
  • Avoid in active malignancy
  • Avoid in recent cardiovascular or thrombotic event
  • Discontinue if no adequate response after 3–4 months

Transfusion

• Avoid when possible (especially transplant candidates)
• Use only for severe or symptomatic anemia (<7 g/dl for asymptomatic and hemodynamically stable adult inpatients, <7.5 g/dl for people undergoing cardiac surgery, or <8 g/dl for those undergoing orthopedic surgery or those with clinically significant cardiovascular disease) or acute bleeding

References:

Iron-Deficiency Anemia in CKD: A Narrative Review for the Kidney Care Team
Hain, Debra et al. Kidney Medicine, Volume 5, Issue 8, 100677

Executive Summary of the KDIGO 2026 Clinical Practice Guideline for the Management of Anemia in Chronic Kidney Disease (CKD) Babitt, Jodie L. et al. Kidney International, Volume 109, Issue 1, 44 – 56

Edited by Aruna Phekoo and Matthew A. Sparks 2/20/2026