Anemia is usually described as a condition where the hemoglobin levels in blood is less than 13.0 g/dL in males and below 12 in females. Anemia that develops in association with chronic kidney disease (CKD) is normocytic, normochromic, and hypo proliferative. This condition is one of the complications that are associated with CKD, and they show poor prognosis and higher mortality rates. 

It is estimated that anemia typically starts manifesting when the Glomerular filtration rate is at 60 mL/min/1.73 m², but increases progressively as GFR deteriorates further, anemia is exceedingly uncommon if GFR is above 80 mL/min/1.73 m². 

The association between anemia and CKD has been known for over 170 years since the discovery by Richard Bright. Anemia tends to develop more frequently as the person has kidney disease especially in the stage 5 CKD. This type of anemia results in decreased health-related quality of life, an increased risk of cardiovascular events, cognitive impairment, more frequent hospitalizations, as well as an increased mortality rate. 

Anemia is usually noticed when the GFR is below 60 mL/min/1.73m2 most often when more than 50% of kidney function is impaired. Anemia associated with CKD typically worsens with the progression of the CKD stage. However, there is a poor correlation between renal erythropoietin production and the degree of anemia with the severity of kidney disease. Chronic kidney disease anemia is common in almost all patients who are on dialysis. 

Chronic kidney disease-related anemia has been found to be related to decreased quality of life, reduced renal survival, increased rate of morbidity and mortality, and increased health care cost. Evidence suggests that the prevalence of anemia in NDD CKD patients may be as high as 60%. 

Thus, as the eGFR blood test value decreases, anemia is more frequent and more severe. National Health and Nutrition Examination Survey (NHANES) data from 2007-2008 and 2009-2010 showed that anemia was more common among CKD patients than non-CKD patients. Similar trends are evident in the present data retrieved from the CKD Prognosis Consortium’s work in the recent past. 

The primary cause of anemia in patients with chronic kidney disease is absence of erythropoietin, but there are additional causes as well. These consist of factors that could be induced by uremia that may inhibit erythropoiesis although the actual inhibitors have not been well characterized. Further, mechanical and metabolic factors reduce the lifespan of red blood cells that also contribute to the disease. 

On the other hand, disturbance of iron homeostasis has come to be appreciated as an important factor more and more. The CKD patients are at a higher risk of getting iron deficient as they experience increased iron losses due to chronic bleeding, blood retention in the dialysis equipment, and many blood draws. This deficiency coupled with a significantly reduced ability to absorb iron makes intravenous iron supplementation more preferential in hemodialysis patients. Another comorbidity found in CKD patients includes functional iron deficiency where though iron is in the body stores it cannot be used for use in red blood cell synthesis. 

The primary factor contributing to anemia in cases of chronic kidney disease (CKD) is the decreased synthesis of erythropoietin (EPO). This decline in EPO has been associated with the suppression of hypoxia-inducible factor (HIF), which is crucial for the expression of the EPO gene. Some of the other factors that may be contributory to anemia in CKD include uremia resulting in deviation in shape and destruction of RBCs, deficiencies of folic acid and vitamin B12, iron deficiency, functional platelet abnormalities that cause hemorrhage, and rarely, hemolysis due to hemodialysis. 

Renal failure is characterized by a poor response to erythropoietin therapy and increased prevalence of cardiac events. These factors include the prevalence of inflammation associated with elevated C-reactive protein (CRP) and iron deficiency; for this reason, iron administration is generally suggested to enhance treatment outcomes. Chronic kidney disease associated anemia is aligned to cardiorenal anemia syndrome; studies have revealed that even a slight lowering of the extent of hemoglobin carries with it a proportionate propensity for heart issues. Cardiovascular diseases are the major cause of death in CKD patients, and anemia which is this case is manifested by low hemoglobin levels is known to increase the risk of hospitalization and mortality. 

Age Group 

• Adults: CKD-related anemia is more prevalent in the adult population especially those who are above 50 years of age because the risk of developing CKD rises with age. 
• Elderly: This is because older patients have reduced renal function due to aging and are generally more susceptible to the development of chronic kidney disease and its complications. 
• Children: However, anemia related to CKD is not rare among children, especially those with congenital or hereditary renal diseases. 

• Pallor: It is noticed in the skin, conjunctiva, and nail beds. 
• Tachycardia: Tachycardia as a compensation mechanism. 
• Shortness of Breath: It usually happens inclusive of exertion or even in normal day to day activities as mentioned a while ago. 
• Fatigue and Weakness: As a rule, generalized and can cause obvious changes in the child’s condition. 
• Cold Extremities: This is due to poor circulation, which in turn leads to the formation of plaque on the walls of arteries. 
• Peripheral Edema: Legs may swell occasionally, especially for those patients who have been diagnosed with congestive heart failure. 

• Diabetes mellitus 
• Hypertension 
• Cardiovascular diseases 
• Autoimmune diseases 

Chronic kidney disease anemia is a progressive process that occurs as the renal function deteriorates and may be asymptomatic in the first stage. The symptoms that manifest during the onset of the disease include fatigue, pallor, shortness of breath, dizziness, weakness and cold intolerance. As the severity of the condition increases, the symptoms would inevitably worsen – with exercise tolerance being decreased, increase in the heart rate, and increase in effects on the existing cardiovascular diseases. 

Manage CKD: 

Treat comorbidities that contribute to the injury (for example, diabetes or hypertension). 

It is also important to make some changes to diet to control the levels of electrolytes and nutrients. 

For advanced CKD, patients may need to undergo hemodialysis or peritoneal dialysis. 

Pharmacological Treatments: 

ESAs (e. g., Epoetin alfa, darbepoetin alfa): Regulate production of red blood cells. 

Iron Supplementation: Administer oral or intravenous iron; to avoid iron toxicity, measure the levels. 

Non-Pharmacological Approaches 

For the desired results some sort of changes are necessary, such as a considerable increase in intake of iron containing foods. 

It implied correction of the causes of anemia including bleeding. 

Monitoring and Follow-Up: 

Biometric assessments at least once a month involving a check-up on hemoglobin and iron levels. 

Monitor patient’s response to treatment and side effects to determine the necessity for change in the treatment plan. 

Dietary Modifications: 

• Iron-Rich Foods: Promote foods with high iron content, including lean meats, poultry, fish, beans, and iron-fortified cereals. 
• Vitamin C: Encourage consumption of foods containing vitamin C (e.g., oranges, lemon, bell peppers) to improve the absorption of the non-heme iron present in plant-based diets. 
• Vitamin B12 and Folate: Continue a diet high in B12 and folate or take a Vitamin B12 supplement if advised by a healthcare provider. 

Nutritional Supplements: 

• Iron Supplements: Patients who are unable to take oral iron or who require a higher dose might have dietary iron augmented with supplements. Check for correct administration of dose an effective dose requires supervision. 
• Vitamin B12 and Folate Supplements: Include supplements as part of the nutrition plan if the client cannot consume adequate amounts of vitamins and minerals or if they are deficient. 

Lifestyle Modifications: 

• Exercise: Promote physical activity and exercise that will enhance general cardiovascular fitness and possibly red blood cell production and utilization. 
• Education: Educate the patients regarding dietary practices in the treatment of anemia and how it augments pharmaceutical therapies. 
• Support Groups: Appliance of psychological components of chronic disease and its treatment, such as enrollment of patients in support groups or counselling. 

Hematology

• Epoetin alfa: Erythropoietin is a cytokine which stimulates the production of red blood cells; this is a recombinant form of it. It is given through an intravenous (IV) or subcutaneous (SC) route of transmission. Usually given at intervals of 2 to 3 days, but the dosing schedule can be adjusted depending on the clinical outcome and the patient’s hemoglobin status. 
• Darbepoetin alfa: A more sustained form of erythropoietin thus implying that it can be administered with less frequency than epoetin alfa. It can also be administered Intravenously or Subcutaneously. Typically given once in one to four weeks based on the dose and the body response of the patient. 
• Methoxy polyethylene glycol-epoetin beta (Mircera): A running EPO stimulator with a tethered half-life of the agent, perhaps requiring administration only once a week. It is administered SC. Administered every 2 to 4 weeks. 

Hematology

• Ferrous Sulfate: It is one of the most widely used types of iron supplements, usually containing 65 mg of iron in the form of ferrous salt per tablet. 
• Ferrous Fumarate: Provides approximately 33 mg of elemental iron per 100 mg, which is about one-third of the total weight of the supplement as iron. 
• Ferrous Gluconate: It is composed of approximately 12% elemental iron; 300 mg of ferrous sulphate yields about 36 mg of elemental iron. 

Hematology

• Iron Supplementation: When it comes to patients with iron deficiency, IV iron is administered more often than oral iron because oral iron is not well absorbed in CKD patients. Procedures may involve: 
• Intravenous Iron Infusions: Given in outpatient care settings like the infusion center. Typical preparations are iron sucrose, ferric gluconate or ferric carboxymaltose. 
• Erythropoiesis-Stimulating Agents (ESAs): ESAs are used to encourage the production of red blood cells. The procedure involves: 
• Subcutaneous or Intravenous Administration: Given in a hospital or any other health care facility. Some ESAs are epoetin alfa and darbepoetin alfa some of the agents that it contains. 
• Blood Transfusions: Those with severe anemia or where there’s no improvement, Blood transfusion may be required. The procedure involves: 
• Transfusion Therapy: These are given in a hospital or an outpatient facility that is an infusion center. 
• Dialysis-related Procedures: For patients who are on dialysis, that management of anemia can also include: 
• Dialysis Modifications: Supplementing the patient’s diet, because low nutrient intake may result to inadequate dialysis that worsens anemia. 

Hematology

• Assessment and Diagnosis: Assess severity of anemia and its potential causes (e.g., level of hemoglobin, iron stocks, vitamin B12, and folate). Decide on the kind of CKD a patient has to start the appropriate management. 
• Treatment of Underlying Causes: Correct scientific or vitamin and mineral deficiencies through dietary supplements. Optimise management of patients with the condition to reduce progression and effects on anemia. 
• Erythropoiesis-Stimulating Agents (ESAs): Prescribe ESAs such as erythropoietin or darbepoetin alpha with the aim of increasing red blood cell mass. Supervise ESA dosing to maintain target hemoglobin concentrations in the patient’s body. 
• Supportive Therapy: Educate that blood transfusion should be given when necessary and be aware of risks. Dosage of medications that may cause anemia or interfere with chosen treatments should be modified accordingly. 
• Long-term Management and Monitoring: It is important to periodically check levels of haemoglobin, iron stores and kidney function. Monitor the patient response and update ESA and iron therapy based on the observational data collected