Anemia of Chronic Kidney Disease in Children Under 18 When ESA Therapy Has Failed
In children under 18 years with anemia and chronic kidney disease, erythropoiesis-stimulating agents (ESAs) are the established first-line treatment. When ESA therapy does not achieve the expected hemoglobin response, a further structured protocol guides the next clinical step.
Clinical scenario
A patient under 18 years of age with anemia in the context of chronic kidney disease. ESAs are effective in this pediatric population and form the basis of initial management; however, a defined escalation pathway exists for cases where first-line ESA therapy is insufficient.
Prior treatment line — why escalation is triggered
Previous treatment: Erythropoiesis-stimulating agent (ESA) as first-line therapy — including epoetin alfa/beta, darbepoetin, methyl polyethylene glycol–epoetin beta, or ESA biosimilars.
Goals not met: A hemoglobin increase of 1.0 g/dl per month was not achieved, or the individualized maintenance hemoglobin target was not reached. Failure to meet these hemoglobin targets is the condition that escalates care to this next-line protocol.
Next-line approach — partial overview
This protocol involves a red blood cell transfusion–based strategy as part of comprehensive management when ESA therapy has proven ineffective. The approach includes specific clinical considerations relevant to children who may be candidates for kidney transplantation. The full decision framework — including when and how this strategy is applied — is available in the complete protocol.
References
DOI: 10.1016/j.kint.2025.06.006
- ESAs are effective in children, while HIF-PHIs have not been studied in children.
- There are insufficient data for efficacy and safety regarding the use of HIF-PHIs for the treatment of children with anemia and CKD G5D or CKD not receiving dialysis.
- In people with anemia and CKD, base the decision to transfuse on symptoms and signs caused by anemia rather than an arbitrary Hb threshold.
- In people with anemia and CKD eligible for organ transplantation, avoid, when possible, RBC transfusions to minimize the risk of allosensitization.
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