Snapshot A 45-year-old man with history of stage 5 chronic kidney disease presents with increased shortness of breath, exercise intolerance, and general weakness. He regularly receives dialysis treatment. On physical exam, he is notably pale. He also has conjunctival pallor. Laboratory results reveal that he is anemic with normal iron levels. His reticulocyte count is low. Given his history of chronic kidney disease, he is started on EPO. Introduction Anemia of renal failure, or anemia of chronic kidney disease is a normochromic, normocytic anemia Pathogenesis erythropoietin (EPO) is synthesized in the kidney EPO stimulates red blood cell (RBC) production in chronic kidney disease, there is decreased EPO production leads to apoptosis of erythroid progenitor cells leads to decreased reticulocyte count and RBC production other factors contributing to anemia in chronic kidney disease include uremic-induced inhibition of RBC production shortened half-life Risk factors decreased glomerular filtration rate angiotensin receptor blockers ACE-inhibitors Presentation Symptoms of anemia, which typically occur if hemoglobin < 10 g/dL fatigue generalized weakness dyspnea lightheadedness Evaluation Anemia hemoglobin < 13 g/dL in men hemoglobin < 12 g/dL in women ↓ Reticulocyte count May have normal iron levels Signs of kidney damage albuminuria electrolyte abnormalities ↓ glomerular filtration rate Differential Diagnosis Anemia of chronic disease Iron deficiency anemia Treatment Medical management erythropoiesis-stimulating agents (e.g., EPO) iron supplement red cell transfusion only in urgent situations with hemodynamic instability Complications Untreated anemia increases the risk for cardiovascular events and progression of CKD For patients with CKD, maintaining hemoglobin of > 12 g/dL will increase the risk of stroke, diabetes, and cardiovascular events