Management of Anemia on Hemodialysis

The definition of anemia is controversial. The WHO defines anemia as hemoglobin (Hb)<13 g/dL for men and <12 g/dL for women [1]. The National Kidney Foundation's Kidney Dis‐ ease Outcomes Quality Initiative, which is the criteria used for Medicare reimbursement, de‐ fines anemia in adult men and postmenopausal women as Hb<12 g/dL, or <11 g/dL in a premenopausal woman [2]. Anemia represents a significant problem to deal with in patients with chronic kidney disease (CKD) on hemodialysis (HD). Renal anemia is typically an iso‐ lated normochromic, normocytic anemia with no leukopenia or thrombocytopenia [3]. This is a frequent complication and contributes considerably to reduced quality of life (QoL) [4-6] of patients with CKD. It has also been associated with a number of adverse clinical out‐ comes, increased morbidity and mortality [5, 7-13]. In general, there is a progressive increase in the incidence and severity of anemia with declining renal function. The reported preva‐ lence of anemia by CKD stage varies significantly and depends, to a large extent, on the def‐ inition of anemia and whether study participants selected from the general population, are at a high risk for CKD. Data from the National Health and Nutrition Examination Survey (NHANES) showed that the distribution of Hb levels starts to fall at an estimated glomeru‐ lar filtration rate (eGFR) of less than 75 ml/min per 1.73 m2 in men and 45 ml/min per 1.73 m2 in women [14]. Among patients under regular care and known to have CKD, the preva‐ lence of anemia was found to be much greater, with mean Hb levels of 12.8 ± 1.5 g/dl (CKD stages 1 and 2), 12.4 ± 1.6 g/dl (CKD stage 3), 12.0 ± 1.6 g/dl (CKD stage4), and 10.9 ± 1.6 g/dl (CKD stage 5) [15]. Although renal anemia is independent of the etiology of kidney disease, there are two important exceptions. Renal anemia in diabetic patients develops more fre‐ quently, at earlier stages of CKD, and more severely at a given level of renal impairment [16-18]. In patients with polycystic kidney disease, Hb is higher than in other patients with similar degrees of renal failure, and polycythemia may occasionally develop [19]. Many pa‐ tients not yet on dialysis still receive no specific treatment for their anemia. In contrast, in