Anemia in Chronic Kidney Disease G5 on Peritoneal Dialysis — When HIF-PHI Therapy Has Not Worked
Patients with chronic kidney disease at stage G5 who are receiving peritoneal dialysis face a high burden of anemia that can be difficult to control. When a structured trial of a hypoxia-inducible factor–prolyl hydroxylase inhibitor (HIF-PHI) does not produce the expected improvement, a next-step strategy is needed.
Clinical Scenario
This protocol addresses anemia in adults with chronic kidney disease G5 who are currently receiving peritoneal dialysis (CKD G5PD) and for whom the preceding treatment step has been unsuccessful.
When the Previous Treatment Did Not Work
The prior step involved a trial course of a HIF-PHI (hypoxia-inducible factor–prolyl hydroxylase inhibitor), given without co-administration of an ESA. The goal was a meaningful erythropoietic response — a demonstrable rise in hemoglobin — within 3 to 4 months, with hemoglobin monitoring every 2 to 4 weeks. This protocol becomes the indicated next step when that hemoglobin response is not achieved within that window.
Next-Step Treatment Approach (Partial Overview)
When both ESA and HIF-PHI therapy prove ineffective or carry unacceptable risk for a given patient, a strategy centred on red blood cell transfusion may be considered as part of a comprehensive care plan — with transfusion decisions based on the patient's symptoms and clinical signs rather than a fixed hemoglobin threshold. Specific additional considerations apply for patients who are transplant candidates.
Full eligibility criteria, clinical decision points, and the complete individualized algorithm are in the structured protocol.
References
- In people with CKD and chronic anemia, consider that the benefits of RBC transfusion may outweigh its harms in people in whom ESA or HIF-PHI therapy is ineffective (e.g., those with hemoglobinopathies, bone marrow failure, or ESA or HIF-PHI resistance) or ESA or HIF-PHI therapy may be harmful (e.g., those with previous or current malignancy or previous stroke).
- In people with anemia and CKD, base the decision to transfuse on symptoms and signs caused by anemia rather than an arbitrary Hb threshold.
DOI: 10.1016/j.kint.2025.06.006
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