Anaemia in Chronic Kidney Disease

Anaemia develops early in the course of Chronic Kidney Disease (CKD) and is nearly universal in patients with CKD stage 5 (End-stage kidney disease).

The prevalence of anaemia at higher levels of glomerular filtration rate (GFR) (i.e. CKD stage 1-2) is relatively low in individuals from the general population.

Anaemia of CKD is primarily caused by deficiency of erythropoietin.

The kidneys are the major source of erythropoietin and, as renal function declines, production of erythropoietin declines proportionately.

Though erythropoietin deficiency is common among patients with anaemia in CKD, other potential causes and contributing disorders should be identified or excluded if initial evaluation yields evidence for disorders other than iron deficiency or erythropoietin deficiency.

Correction of anaemia in CKD patients improves survival and quality of life.

Causes of Anaemia in Chronic Kidney Disease

The following are the causes of anaemia in CKD:

  1. Deficiency of erythropoietin
  2. Red cell destruction from microvascular disease from diabetes or hypertension
  3. Increased gastrointestinal bleeding
  4. Increased oxidative stress leading to shortened red cell survival

Symptoms of Anaemia in Chronic Kidney Disease

(See ‘Anaemia’¬†for the symptoms)

Signs of Anaemia in Chronic Kidney Disease

(See ‘Anaemia’ for the signs¬†


  • FBC
  • Reticulocyte count
  • Transferrin saturation
  • Serum ferritin
  • Stool occult blood

Treatment for Anaemia in Chronic Kidney Disease

Treatment objectives

Treatment objectives of anemia in CKD include the following:

  1. To achieve and maintain a target-range Hb level of 11-12 g/dL
  2. To improve the quality of life of the patients

Non-pharmacological treatment

(See ‘Anaemia’)

Pharmacological treatment

A. CKD Stages 1-2

1st Line Treatment

Evidence Rating: [A]

Ferrous sulphate, oral,

  • 325 mg 8 hourly for 4 weeks

B. CKD Stages 3-4

Iron replacement:

  • Target Hb should be 11-12 g/dL

Ferrous sulphate, oral, 325 mg 8 hourly


Ferrous gluconate, oral, 300 mg 8-12 hourly. Evaluate after 4-6 weeks


Iron sucrose, IV, consult specialist


Ferric sodium gluconate complex, consult specialist


Epoietin beta, SC, consult specialist


Methoxy polyethylene glycol epoietin beta (pegylated form of Epo), SC, consult specialist


Darbepoietin alfa, SC, consult specialist

Referral Criteria

Refer all (adults and children) patients with CKD and anaemia to a specialist or nephrologist.

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