Title: Update on Anemia in ESRD and Earlier Stages of CKD: Core Curriculum 2018
Abstract: Anemia is a frequent complication during the later stages of chronic kidney disease. When present, it may cause symptoms such as fatigue and shortness of breath. The pathogenesis of anemia in chronic kidney disease is complex, but a central feature is a relative deficit of erythropoietin. New information has elucidated the critical role of the hypoxia-sensing system in mediating erythropoietin synthesis and release. Iron deficiency is a second important factor in the anemia of chronic kidney disease. New insights into the dynamics of iron metabolism have clarified the role of chronic inflammation and hepcidin as key mediators of impaired iron utilization. In this article, we review the epidemiology, pathobiology, clinical evaluation, and treatment of anemia in chronic kidney disease. Anemia is a frequent complication during the later stages of chronic kidney disease. When present, it may cause symptoms such as fatigue and shortness of breath. The pathogenesis of anemia in chronic kidney disease is complex, but a central feature is a relative deficit of erythropoietin. New information has elucidated the critical role of the hypoxia-sensing system in mediating erythropoietin synthesis and release. Iron deficiency is a second important factor in the anemia of chronic kidney disease. New insights into the dynamics of iron metabolism have clarified the role of chronic inflammation and hepcidin as key mediators of impaired iron utilization. In this article, we review the epidemiology, pathobiology, clinical evaluation, and treatment of anemia in chronic kidney disease. FEATURE EDITOR:Asghar RastegarADVISORY BOARD:Ursula C. BrewsterMichael ChoiAnn O’HareManoocher SoleimaniThe Core Curriculum aims to give trainees in nephrology a strong knowledge base in core topics in the specialty by providing an overview of the topic and citing key references, including the foundational literature that led to current clinical approaches. FEATURE EDITOR: Asghar Rastegar ADVISORY BOARD: Ursula C. Brewster Michael Choi Ann O’Hare Manoocher Soleimani The Core Curriculum aims to give trainees in nephrology a strong knowledge base in core topics in the specialty by providing an overview of the topic and citing key references, including the foundational literature that led to current clinical approaches. Case: A 54-year-old man with diabetes mellitus, hypertension, and coronary artery disease is being treated for chronic kidney disease (CKD). His estimated glomerular filtration rate has declined over the past 2 years from 40 to 14 mL/min/1.73 m2. The patient reports increased fatigue and asks about the causes of his anemia. Red blood cell indexes are normal, and iron test results and serum folate and vitamin B12 concentrations are found to be normal.Question 1: What is the most likely cause or causes of the patient’s anemia?a)Diabetes mellitusb)Relative erythropoietin deficiencyc)Iron deficiencyd)Multiple myelomaFor answer, see Appendix. Case: A 54-year-old man with diabetes mellitus, hypertension, and coronary artery disease is being treated for chronic kidney disease (CKD). His estimated glomerular filtration rate has declined over the past 2 years from 40 to 14 mL/min/1.73 m2. The patient reports increased fatigue and asks about the causes of his anemia. Red blood cell indexes are normal, and iron test results and serum folate and vitamin B12 concentrations are found to be normal. Question 1: What is the most likely cause or causes of the patient’s anemia?a)Diabetes mellitusb)Relative erythropoietin deficiencyc)Iron deficiencyd)Multiple myeloma For answer, see Appendix.