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Anemia and
Chronic Kidney Disease
Stages 1–4

National Kidney Foundation’s
Kidney Disease Outcomes
Quality Initiative
did you know that the National Kidney
Foundation’s Kidney disease outcomes
Quality initiative (NKF-KdoQi) develops
guidelines that help your doctor and
health care team make important deci-
sions about your medical treatment? the
information in this booklet is based on
the NKF-KdoQi™ recommended guide-
lines for anemia.
Stages of Chronic Kidney
there are five stages of chronic kidney
disease. they are shown in the table
below. your doctor determines your stage
of kidney disease based on the presence
of kidney damage and your glomerular
filtration rate (GFR)
, which is a measure
of your level of kidney function. your treat-
ment is based on your stage of kidney
disease. Speak to your doctor if you
have any questions about your stage of
kidney disease or your treatment.
Stages of Kidney Disease
Glomerular Filtration Rate (GFR)*
Kidney damage (e.g., protein
in the urine) with normal GFR
90 or above
Kidney damage with mild
decrease in GFR
60 to 89
Moderate decrease in GFR
30 to 59
Severe reduction in GFR
15 to 29
Kidney failure
Less than 15
*your GFR number tells your doctor how much kidney function you have.
as chronic kidney disease progresses, your GFR number decreases.

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What is anemia?
anemia happens when your red blood
cel s are in short supply. Red blood cel s
carry oxygen from your lungs to all parts of
your body, giving you the energy you need
for your daily activities.
anemia can cause you to:
n look pale
n Feel tired
n Have lit le energy for your
daily activities
n Have a poor appetite
n Have trouble sleeping
n Have trouble thinking clearly
n Feel dizzy or have headaches
n Have a rapid heartbeat
n Feel short of breath
n Feel depressed or “down in the dumps”
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What are some causes of anemia?
anemia can be caused by:
n diseases like kidney disease, liver dis-
ease, HiV/aidS, systemic lupus erythe-
matosus or cancer
n diseases that harm or destroy your
blood cel s, such as sickle cell disease
n Blood loss from accidents, surgery,
stomach ulcers, kidney or bladder
tumors, cancer or polyps in the intes-
tines or other causes
n an infection or inflammation in
your body
n too lit le iron, vitamin B12 or folic acid
in your body
iron is a mineral that you get from eat-
ing foods like liver and leafy, green
vegetables. Both vitamin B12 and
folic acid are important vitamins that
you get from eating foods like eggs,
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fish and liver. your body needs these
important minerals and vitamins to help
make red blood cells.
n a poor diet
you can become anemic if you do not
eat healthy foods with enough vitamin
B12, folic acid and iron. your body
needs these important vitamins and
minerals to help make red blood cells.
Before starting anemia treatment, your doc-
tor will order tests to find the exact cause of
your anemia.
Why do people with kidney
disease get anemia?
your kidneys make an important hormone
cal ed erythropoietin (EPO). Hormones are
secretions that your body makes to help
your body work and keep you healthy.
ePo tel s your body to make red blood
cel s. When you have kidney disease, your
kidneys cannot make enough ePo. this
causes your red blood cell count to drop
and anemia to develop.
Are all people with kidney
disease at risk for anemia?
Most people with kidney disease will devel-
op anemia. anemia can happen early in
the course of kidney disease and grow
worse as kidneys lose their ability to work
well and make ePo. anemia is especially
common if you:
n Have diabetes
n are african american
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n Have moderate or severe loss of
kidney function (stage 3 or 4)
n Have kidney failure (stage 5)
n are female
if you are african american or have
diabetes and chronic kidney disease,
you are more likely to have anemia
and get it at an earlier stage of
kidney disease.

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How do I know if I have anemia?
Not everyone with anemia has symptoms.
if you have kidney disease, you should
have a blood test to measure your hemo-
globin level at least once per year to check
for anemia. Hemoglobin is the part of red
blood cel s that carries oxygen throughout
your body. your doctor can tell if you have
anemia by measuring your hemoglobin. if
your hemoglobin level is lower than the nor-
mal range (which is 12.0 for women and
13.5 for men), it is likely you have anemia.
in that case your doctor will check to find
the exact cause of your anemia and develop
a treatment plan that is right for you.
Speak to your doctor if you think you
have anemia. Make a list of questions.
Write down your symptoms, allergies,
medications, previous medical pro-
cedures, and other health problems.
Show the list of symptoms to your doc-
tor. discuss how you are feeling and
ask questions.
How is anemia treated?
your treatment will depend on the exact
cause of your anemia. if your anemia is due
to kidney disease, you will be treated with:
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n drugs cal ed erythropoiesis-stimulating
agents (ESAs)
eSas help your body make red blood
cells. eSas will usually be given to you
as an injection under the skin (called
a subcutaneous injection) in your
doctor’s office.
n extra iron
your body also needs iron to make
red blood cells—especially when you
are receiving eSas. Without enough
iron, your eSa treatment will not work.
iron can be given to you as a pill by
mouth, or administered directly into a
vein in your doctor’s office or clinic.
Not having enough ePo (a hormone
made by your kidneys) is the most
common cause of anemia in patients
with kidney disease. ePo tel s your
body to make red blood cel s. When
your kidneys no longer make enough
ePo, treatment with an eSa can help.
What is the goal of
anemia treatment?
the goal of anemia treatment is to increase
your hemoglobin level to at least 11, which is
considered to be the lowest level of hemoglo-
bin you need to feel wel . as you get closer to
or pass this level, you should notice that you
have more energy and feel less tired.

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How much ESA will I need?
your doctor will prescribe enough eSa
to increase your hemoglobin gradually to
the recommended level. How much eSa
you need and how often you receive it
depends on:
n your current hemoglobin level
n How well you respond to treatment
with eSa
n the type of eSa you receive
there are different types of eSas avail-
able—short-acting eSas or long-lasting
eSas. you and your doctor will decide
which type is best for you.
it’s important to speak to your doctor if
you are ever discharged from a hospital.
your doctor may want to modify your
anemia treatment plan so that your target
hemoglobin is maintained.
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How will my doctor know if I am
responding to ESA?
your doctor will check your hemoglobin
level at least monthly. this tel s your doctor
how well you are doing. your dose of eSa
may need to be changed, depending on
how well you respond to your treatment.
Will I need extra iron?
your body needs iron to make red blood
cel s. once you start taking an eSa your
body will make more red blood cel s, and
your body’s iron supply will be used up
faster. Without extra iron, your eSa treat-
ment will not be effective.
How much iron will I need?
your doctor will decide how much iron you
need and how often you get it based on
your hemoglobin level, eSa dose, and the
results of your iron tests. the goal of taking
extra iron is to make sure you have enough
iron to reach a hemoglobin of at least 11.
iron is important in treating anemia.
Without enough iron, eSa is wasted
and you will not reach your target
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