Anemia in Kidney Disease and DialysisIf your blood is low in red blood cells,you have anemia. Red blood cellscarry oxygen (O2) to tissues andorgans throughout your body and enablethem to use the energy from food.Without oxygen, these tissues andorgansparticularly the heart andbrainmay not do their jobs as well asthey should. For this reason, if you haveanemia, you may tire easily and lookpale. Anemia may also contribute toheart problems.

Anemia is common in people with kid-ney disease. Healthy kidneys produce ahormone called erythropoietin, or EPO,which stimulates the bone marrow toproduce the proper number of redblood cells needed to carry oxygen tovital organs. Diseased kidneys, how-ever, often dont make enough EPO. Asa result, the bone marrow makes fewerred blood cells. Other common causesof anemia include loss of blood fromhemodialysis and low levels of iron and folic acid. These nutrients fromfood help young red blood cells makehemoglobin (Hgb), their main oxygen-carrying protein.

Laboratory TestsA complete blood count (CBC), a labora-tory test performed on a sample of yourblood, includes a determination of yourhematocrit (Hct), the percentage of theblood that consists of red blood cells.The CBC also measures the amount ofHgb in your blood. The range of normalHct and Hgb in women who menstruateis slightly lower than for healthy men or

Healthy kidneys produce a hormone called erythropoi-etin, or EPO, which stimulates the bone marrow tomake red blood cells needed to carry oxygen (O2)throughout the body.

Diseased kidneys dont make enough EPO, and bonemarrow then makes fewer red blood cells.

National Institute of Diabetes and Digestive and Kidney DiseasesNATIONAL INSTITUTES OF HEALTH

U.S. Department of Healthand Human Services

healthy postmenopausal women. The Hgb isusually about one-third the value of the Hct.

When Anemia BeginsAnemia may begin to develop in the earlystages of kidney disease, when you still have20 percent to 50 percent of your normal kid-ney function. This partial loss of kidney func-tion is often called chronic renal insufficiency.Anemia tends to worsen as kidney disease pro-gresses. End-stage kidney failure, the pointat which dialysis or kidney transplantationbecomes necessary, doesnt occur until youhave only about 10 percent of your kidneyfunction remaining. Nearly everyone withend-stage kidney failure has anemia.

DiagnosisIf you have lost at least half of normal kidneyfunction (based on your glomerular filtrationrate calculated using your serum creatininemeasurement) and have a low Hct, the mostlikely cause of anemia is decreased EPO pro-duction. The National Kidney FoundationsDialysis Outcomes Quality Initiative (DOQI)recommends that doctors begin a detailedevaluation of anemia in men and postmeno-pausal women on dialysis when the Hct valuefalls below 37 percent. For women of child-bearing age, evaluation should begin when theHct falls below 33 percent. The evaluationwill include tests for iron deficiency and bloodloss in the stool to be certain there are noother reasons for the anemia.

TreatmentEPOIf no other cause for EPO deficiency is found,it can be treated with a genetically engineeredform of the hormone, which is usually injectedunder the skin two or three times a week.Hemodialysis patients who cant tolerate EPOshots may receive the hormone intravenouslyduring treatment, but this method requires alarger, more expensive dose and may not be aseffective. DOQI recommends that patients

treated with EPO therapy should achieve atarget Hgb of 11 to 12 g/dL.

IronMany people with kidney disease need bothEPO and iron supplements to raise their Hctto a satisfactory level. If your iron levels aretoo low, EPO wont help and youll continueto experience the effects of anemia. You maybe able to take an iron pill, but many studiesshow that iron pills dont work as well inpeople with kidney failure as iron given intra-venously. Iron is injected directly into an armor into the tube that returns blood to yourbody during hemodialysis.

A nurse or doctor will give you a test dosebecause a very small number of people (lessthan 1 percent) have a bad reaction to ironinjections. If you begin to wheeze or havetrouble breathing, your health care providercan administer epinephrine or corticosteroidsto counter the reaction. Even though the riskis small, youll be asked to sign a form statingthat you understand the possible reaction andthat you agree to have the treatment. Talkwith your health care provider if you have anyquestions.

In addition to measuring your Hct and Hgb,your tests will also include two measurementsto show whether you have enough iron.

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When to Evaluate Dialysis Patients for Anemia

Hematocrit Hemoglobin(Hct) (Hgb)

Women who less than less thanmenstruate 33% 11 g/dL

All men and less than less thanpostmenopausal 37% 12 g/dLwomen

Source: The National Kidney Foundations DialysisOutcomes Quality Initiative.

Your ferritin level indicates the amount ofiron stored in your body. According toDOQI guidelines, your ferritin score shouldbe no less than 100 micrograms per liter(mcg/L) and no more than 800 mcg/L.

TSAT stands for transferrin saturation,a score that indicates how much iron isavailable to make red blood cells. DOQIguidelines call for a TSAT score between20 percent and 50 percent.

Other Causes of AnemiaIn addition to EPO and iron, a few peoplemay also need vitamin B12 and folic acidsupplements.

If EPO, iron, vitamin B12, and folic acid allfail, your doctor should look for other causessuch as sickle cell disease or an inflammatoryproblem. At one time, aluminum poisoningcontributed to anemia in people with kidneyfailure because many phosphate binders usedto treat bone disease caused by kidney failurewere antacids that contained aluminum. Butaluminum-free alternatives are now widelyavailable. Be sure your phosphate binder andyour other drugs are free of aluminum.

Anemia keeps many people with kidney dis-ease from feeling their best. But EPO treat-ments help most patients raise their Hgb, feelbetter, live longer, and have more energy.

Hope Through ResearchThe National Institute of Diabetes and Diges-tive and Kidney Diseases (NIDDK), throughits Division of Kidney, Urologic, and Hemato-logic Diseases, supports several programs andstudies devoted to improving treatment forpatients with progressive kidney disease andend-stage kidney failure, which is sometimescalled end-stage renal disease or ESRD, includ-ing patients on hemodialysis:

The End-Stage Renal Disease Program.This program promotes research to reducemedical problems from bone, blood, ner-vous system, metabolic, gastrointestinal,cardiovascular, and endocrine abnormalities

in end-stage kidney failure and to improvethe effectiveness of dialysis and transplan-tation. The research focuses on reuse ofhemodialysis membranes and on usingalternative dialyzer sterilization methods;on devising more efficient, biocompatiblemembranes; on refining high-flux hemo-dialysis; and on developing criteria fordialysis adequacy. The program also seeksto increase kidney graft and patient survivaland to maximize quality of life.

The Frequent Hemodialysis Network.This multicenter clinical trial will testwhether receiving hemodialysis more thanthree times a week provides better out-comes than the normal schedule of threesessions per week.

The U.S. Renal Data System (USRDS).This national data system collects, analyzes,and distributes information about the use ofdialysis and transplantation to treat kidneyfailure in the United States. The USRDS isfunded directly by NIDDK in conjunctionwith the Centers for Medicare & MedicaidServices. The USRDS publishes an AnnualData Report, which characterizes the totalpopulation of people being treated forkidney failure; reports on incidence, preva-lence, mortality rates, and trends over time;and develops data on the effects of varioustreatment modalities. The report also helpsidentify problems and opportunities formore focused special studies of renalresearch issues.

The Hemodialysis Vascular Access ClinicalTrials Consortium is conducting a seriesof multicenter, randomized, placebo-controlled clinical trials of drug therapiesto reduce the failure and complication rateof arteriovenous grafts and fistulas inhemodialysis. Recently developedantithrombotic agents and drugs to inhibitcytokines are being evaluated in these largeclinical trials.

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For More InformationFor more information, contact thefollowing organizations:

American Association of Kidney Patients

3505 East Frontage RoadSuite 315Tampa, FL 33607Phone: 18007492257Fax: 8136368122 Email: info@aakp.orgInternet: www.aakp.org

American Kidney Fund 6110 Executive BoulevardSuite 1010 Rockville, MD 20852Phone: 18006388299 Fax: 3018810898Email: helpline@akfinc.org Internet: www.kidneyfund.org

National Kidney Foundation30 East 33rd StreetNew York, NY 10016Phone: 18006229010 or2128892210Fax: 2126899261Email: info@kidney.orgInternet: www.kidney.org

About the Kidney Failure SeriesThe NIDDK Kidney Failure Seriesincludes six booklets and seven factsheets that can help you learn moreabout treatment methods for kidneyfailure, complications of dialysis,financial help for the treatment ofkidney failure, and eating right onhemodialysis. For free single printedcopies of this series, please contact theNational Kidney and Urologic DiseasesInformation Clearinghouse.

National Kidney and UrologicDiseases Information Clearinghouse3 Information WayBethesda, MD 208923580Phone: 18008915390Fax: 7037384929Email: nkudic@info.niddk.nih.govInternet: www.kidney.niddk.nih.gov

The National Kidney and Urologic DiseasesInformation Clearinghouse (NKUDIC) is aservice of the National Institute of Diabetesand Digestive and Kidney Diseases (NIDDK).The NIDDK is part of the National Institutesof Health under the U.S. Department ofHealth and Human Services. Establishedin 1987, the Clearinghouse provides infor-mation about diseases of the kidneys andurologic system to people with kidney andurologic disorders and to their families,health care professionals, and the public.The NKUDIC answers inquiries, developsand distributes publications, and worksclosely with professional and patient organi-zations and Government agencies to coordi-nate resources about kidney and urologicdiseases.

Publications produced by the Clearinghouseare carefully reviewed by both NIDDK scien-tists and outside experts. This fact sheet wasalso reviewed by Dr. John C. Stivelman,Emory University School of Medicine.

U.S. DEPARTMENT OF HEALTHAND HUMAN SERVICESNational Institutes of Health

NIH Publication No. 054619January 2005

This publication is not copyrighted.The Clearinghouse encourages usersof this fact sheet to duplicate anddistribute as many copies as desired.

This fact sheet is also available atwww.kidney.niddk.nih.gov.