Anemia of chronic kidney disease
ICD-10 D63.1 · ICD-11 3A71.2

Anemia in Chronic Kidney Disease G5 on Peritoneal Dialysis — After Erythropoiesis-Stimulating Agent Hyporesponsiveness

Clinical scenario

This protocol applies to patients with anemia and stage G5 chronic kidney disease who are receiving peritoneal dialysis and have demonstrated an inadequate hemoglobin response to first-line erythropoiesis-stimulating agent (ESA) therapy.

Previous treatment — failure condition

First-line therapy with an erythropoiesis-stimulating agent (ESA) — the preferred initial approach in this population — did not achieve its targets: a rise in hemoglobin of 1.0 g/dl per month while keeping hemoglobin below 11.5 g/dl. This pattern of ESA hyporesponsiveness is the clinical condition that warrants escalation to the next management step.

Next-line approach (partial overview)

When ESA hyporesponsiveness is established, the structured protocol addresses whether a trial of a fundamentally different class of erythropoiesis-promoting therapy — a hypoxia-inducible factor–prolyl hydroxylase inhibitor (HIF-PHI) — is appropriate. Critically, this agent class is used as a standalone intervention and must not be combined with an ESA. The choice of specific agent, its starting dose, monitoring parameters, and the complete management algorithm are detailed in the full protocol.

Clinical goals

The target is a meaningful erythropoietic response — a measurable rise in hemoglobin — assessed within 3–4 months of starting treatment. Hemoglobin levels are monitored 2–4 weeks after initiation and every 4 weeks throughout therapy. If the desired response is not achieved by 3–4 months, the approach is reassessed.

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References

DOI: 10.1016/j.kint.2025.06.006

In people with CKD, anemia, and ESA hyporesponsiveness, if there is a desire to raise Hb to avoid transfusion or improve symptoms attributable to anemia, a trial course of HIF-PHI may be considered after discussion of potential risks and benefits (Figure 10).

In people with anemia and CKD, including those with ESA hyporesponsiveness, do not use ESAs and HIF-PHIs in combination.

In people with anemia and CKD, discontinue HIF-PHI after 3–4 months if a desired erythropoietic response has not been achieved.

In people with anemia and CKD, when administering HIF-PHIs, monitor Hb levels 2–4 weeks after initiation or dose adjustments and subsequently every 4 weeks during therapy.

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