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Last Updated 09/10/17

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Anemia is a common complication of end-stage renal disease (ESRD). Anemia occurs when there is a shortage of red blood cells or when the red blood cells are not correctly formed. In dialysis units, anemia is usually measured by the hematocrit blood test, which reports the percentage of the blood that is comprised of red blood cells. Normally, a hematocrit is from 37% to 47% for women and from 42% to 52% for men. Without interventions, a dialysis patient's hematocrit usually stabilizes between 20-25%. At this level, most patients tire easily and feel drained of energy. Several statistical analyses have shown that dialysis patients have signficantly more complications, hospitalizations, and a higher mortality rate when their hematocrit is below 30% (approximately).

Dialysis patients experience anemia (low hematocrit) primarily because their kidneys no longer produce adequate amounts of erythropoietin (EPO). EPO is the principal factor that stimulates red blood cell production in the bone marrow.

Before 1990, most dialysis patients experienced moderate to severe anemia on a long-term basis. At that time, dialysis patients were given frequent blood transfusions which also exposed them to possible infection by bloodborne pathogens such as hepatitis viruses and HIV. Today, thanks to the availability of bioengineered EPO, the need for most transfusions has been eliminated.

With most patients now routinely receiving EPO during their dialysis treatments, hematocrits are routinely in the range of 30-36%. The NKF-DOQI recommended target hematocrit range for dialysis patients currently is 33% to 36%. Most insurance companies and Medicare will not reimburse the dialysis facilities for EPO injections when the patient's hematocrit is above a certain number (36% approximately).

The production of healthy blood cells is also dependent on the body having enough iron, vitamin B12, folic acid and other substances. If a patient does not respond to EPO therapy, the most likely cause is a deficiency of iron. For this reason, most dialysis centers routinely monitor iron levels in the blood.

Warning:  Changes should never be made in a patient's treatment or care based solely on the information found here.  Every patient has unique healthcare concerns and considerations and all these factors must all be taken into account before any changes can be safely made.  All medical and therapeutic decisions must come from a qualified health care provider.  Read RenalWEB's Legal Disclaimer before proceeding.


  NEWS & LATEST ARTICLES
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Association of Erythropoiesis-Stimulating Agents and the Incidence Risk of Cancer Diagnosis Among Chronic Dialysis Patients - NDT article - Article from Medscape Nephrology (registration required, but free). - September 2017

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Iron Overload in Dialysis Patients: Rust or Bust? - 8-page pdf - Article in Press Abstract and Full-Text PDF from Kidney International Reports. - September 1, 2017

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How Many Nurses Does It Take To Change a Patient's Blood? - Editorial from Los Angeles Times. News release from NO on SB 349. - August 21, 2017

Editor's note: In terms of knowledge and expertise on this topic, the headline says it all.

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Researchers: Iron-based Binders Best for Hyperphosphatemia - Article from Renal & Urology News. - August 21, 2017

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De novo Weekly and Biweekly Darbepoetin Alfa Dosing in Pediatric Patients with Chronic Kidney Disease - First Online abstract from Pediatric Nephrology. - August 17, 2017

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  ESSENTIALS AND CLASSICS
blue ball Anemia Management quality improvement from The Renal Network (ESRD Network 9/10) web page
Anemia Fact Sheet (pdf format requires Adobe Acrobat reader.) from the American Nephrology Nurses’ Association
Information on Erythropoiesis-Stimulating Agents (ESAs) and Q&A page - from the U. S. Food and Drug Administration (FDA)
Iron Supplementation in Hemodialysis - Practical Clinical Guidelines (pdf format requires Adobe Acrobat reader) from Nephrology Dialysis Transplantation (NDT) - October 1998

Kidney Disease: Improving Global Outcomes — Guidelines on Anemia Management in Chronic Kidney Disease: a European Renal Best Practice Position Statement - Free, full-text article from NDT. - June 2013

Revised European Best Practice Guidelines for the Management of Anaemia in Patients with Chronic Renal Failure - guidelines endorsed by the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA)
What You Need to Know About Anemia and Chronic Kidney Disease from The National Kidney Foundation (NKF)
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  WEB RESOURCES
Latest Scientific Journal Articles on Anemia Continually Updated!
blue ball Anemia - this is a growing library of key high-impact articles in nephrology, chosen by UKidney's contributors as suggested reading for nephrology trainees and practitioners.
Anemia in children with chronic kidney disease - full-text educational feature from Pediatric Nephrology - February 2008
Anaemia Nurse Specialist Association - UK web site
Dialysis Facility Compare - Medicare's comparison of the quality of care that is provided at dialysis facilities throughout the United States and its territories includes information on anemia management
Drug and Supplements Info: Epoetin and Iron from National Library of Medicine MedLine Plus
Just the Facts: Anemia and Información esencial: Anemia (pdf format requires Adobe Acrobat Reader) from the Life Options web site
blue ball Treatment of Anemia in Patients With Heart Disease: A Clinical Practice Guideline From the American College of Physicians article from the Annals of Internal Medicine - December 2013
Understanding Anemia in Kidney Disease from the AAKP web site
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  PUBMED SEARCHES (National Library of Medicine's MEDLINE Database)
anemia AND dialysis   Continually Updated!
EPO AND dialysis   Continually Updated!
MEDLINE / Pubmed Information from the National Library of Medicine
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  K/DOQI™ -  Kidney Disease Outcomes Quality Initiative

KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease (2006)

KDOQI Clinical Practice Guideline and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease: 2007 Update of Hemoglobin Target

K/DOQI Home Page from the National Kidney Foundation web site
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  KDIGO™ -  Kidney Disease: Improving Global Outcomes

Anemia in CKD - Clinical Practice Guidelines for the Treatment of Anemia of Chronic Renal Failure

  1. Download complete Anemia Guideline in English (PDF 1.3MB)
  2. Download Supplementary Materials: Online Appendices 1-2 (PDF 1.3MB)
  3. Download Supplementary Tables (PDF 502KB)
KDIGO Home Page


  DISCUSSION FORUM
General Dialysis Nursing Issues and Questions (No dedicated RenalWEB forum yet for this topic)
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  PRODUCTS
 
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  INPUT / SUGGESTIONS
E-mail to RenalWEB on the Adequate Hematocrit Topic
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