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The link between anemia and chronic kidney disease

The link between anemia and chronic kidney disease

Anemia is a common complication for those with chronic kidney disease. If hemoglobin levels don’t improve with iron medications, doctors suggest a kidney function test

If the hemoglobin levels don’t improve with iron medications, doctors suggest a kidney function test

Anemia might not just indicate an iron deficiency. It could also point to chronic kidney disease (CKD).

Dr Sankaran Sundar, director, Aster Institute of Renal Transplantation, Aster Whitefield, Bengaluru, explains how this could be true. “Kidneys make a hormone called erythropoietin or EPO,” he says. EPO is a hormone responsible for the production of red blood cells which carry hemoglobin. “When kidney function is affected, it also leads to a decline in the production of EPO,” he notes. Less EPO eventually means fewer RBCs and thus less hemoglobin.  “And this can cause anemia.”

He points out that anemia is common in people with long-standing chronic kidney disease. While the normal range of hemoglogin for men is 13 to 16 grams per decilitre and for women is 12 to 15, those battling CKD face low levels of hemoglobin.


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Prevalence of anemia in people with chronic kidney disease

According to doctors, anemia can affect a person in the early stages of CKD itself. However, it is common in those who are in the advanced stage of CKD.

The prevalence of anemia is 8.4 per cent at stage 1 and 53.4 per cent at stage 5 of CKD, says Dr Sundar quoting a US study. “However, in the Indian scenario, nearly 95 per cent of those in CKD-stage 5 are anemic, as per a 2016 cross-sectional study,” he adds.

“Anemia is not only iron deficiency but also erythropoietin deficiency. We have to see what’s the cause of anemia,” says Dr Sanjeev Gulati, director, nephrology, Fortis Hospital, Vasant Kunj, New Delhi.

Managing anemia and CKD

Mohit Dhawan, 39, a businessman from Noida, has had kidney disorders since his birth. When he was five years old, doctors diagnosed the condition as chronic kidney disease. He managed with medications till the age of 23 when he had to resort to dialysis.

“Not all those with CKD are aware of their anaemia until the obvious symptoms manifest,” says Mohit.

To manage his anemia, Dhawan was on erythropoietin and iron injections for more than 13 years. But because his dialysis has been increased to four times a week (since 2020), his hemoglobin level has increased. “Now I am not taking EPO injections but I am on other medicines,” Dhawan tells Happiest Health.

Dr Sanjeev Gulati, who is also the president of the Indian Society of Nephrology says that dialysis removes toxins in the body and reduces the toxic burden on the kidneys. “That helps in the improvement of anemia. But along with that, we give medicines. It cannot happen by dialysis alone,” he adds.

Anemia can be a symptom of CKD

Dr Sundar, the former chairman of the Indian Society of Nephrology underlines that anemia should not be perceived solely as an iron deficiency. “Anybody who has anemia which is not controlled with iron and folic acid must be investigated for a kidney disorder,” he says.

“Kidney plays a critical role in haemoglobin production and blood formation. Fatigue is the result of low hemoglobin. Anemia can be a symptom of a renal disorder,” says Dr Gulati. He adds that a kidney test in children and young adults with anemia could reveal a kidney disease.

Dr Sundar says that he has come across many cases where anemia is managed through iron medications. “All that glitters is not gold and all anemias are not iron deficiencies. If anemia is severe, a kidney function test is a must,” says Dr Sundar.

How to treat anemia in people with chronic kidney disease

The primary line of treatment is erythropoiesis-stimulating agents (ESA) injections, iron medication and in some cases blood transfusion, say doctors.

Besides, new drugs are now available for correcting anemia in CKD, says Dr Sundar. “Earlier only injectable ESA were available. Now we have oral drugs called HIF for treating anemia. Hypoxia-Inducible Factor (HIF) is an enzyme inhibitor, a new class of medicines for the treatment of anaemia in CKD,” he points out.

Dr Sundar adds that the last resort is blood transfusion. With blood transfusion, the red blood cells increase and so does haemoglobin. However, the antibodies will also increase, posing the risk of organ rejection in people who have undergone kidney transplants. “So, we try to avoid blood transfusion before transplant unless it is an emergency. Our policy is not to transfuse unless the hemoglobin is below seven,” says Dr Sundar.

Dr Gulati also says that blood transfusion is not encouraged and is carried out only in pressing situations. “If the haemoglobin levels are very low – five or six – then it is an emergency and we give blood transfusions.”


  • If your hemoglobin level continues to be low, do consult your doctor.
  • If the hemoglobin levels don’t improve with iron medications, doctors suggest a kidney function test.
  • Most people with CKD also have anemia and require treatment for correcting the hemoglobin levels.

Share Your Experience/Comments

2 Responses

  1. I’m transplant patient with law Hb but with transfusion and EPO injection Hb is no improving. What to do next

    1. Thanks for reaching out to us. We at Happiest Health do not provide any medical advice.

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