Synopsis
Distinguish renal anaemia from treatable alternatives, assess iron availability correctly, and use iron, erythropoietic therapy and transfusion safely.
- CKD anaemia is usually isolated, normocytic and hypoproliferative, becoming more plausible below eGFR 30 mL/min/1.73 m², but blood loss, iron or vitamin deficiency, inflammation, haemolysis and marrow disease must still be excluded.
- The 2024 UK Kidney Association guideline advises investigation when haemoglobin is below 110 g/L or symptoms are attributable to anaemia, regardless of CKD stage or dialysis status.
- Do not measure serum erythropoietin routinely: concentrations do not reliably separate renal anaemia or guide treatment.
Key red flags
Haemodynamic instability, active haemorrhage, syncope, ischaemic chest pain or severe hypoxia with anaemia needs urgent resuscitation, crossmatch and transfusion assessment rather than waiting for iron or ESA response.
Investigation priorities
Define severity, cell size and whether abnormalities extend beyond the erythroid line.
Management branches
Haemoglobin falls below 110 g/L or symptoms plausibly relate to anaemia.
- Assess urgency, bleeding, cardiovascular symptoms and trajectory, and compare renal stage with the severity and morphology of anaemia.
- Obtain FBC indices, reticulocytes, iron availability and CRP, adding B12, folate, haemolysis, paraprotein or marrow testing according to phenotype.
Key medicines
Oral ironUse the locally selected elemental-iron preparation and BNF regimen, adjusting frequency for tolerance and assessing response over the agreed trial interval.
Intravenous ironCalculate and administer the preparation-specific replacement or maintenance course under the current SmPC and renal protocol, with trained resuscitation support available.