This protocol addresses patients with chronic kidney disease not receiving dialysis — including kidney transplant recipients — who have anemia and whose prior trial of hypoxia-inducible factor–prolyl hydroxylase inhibitor (HIF-PHI) therapy did not achieve the desired erythropoietic response.
The patient has anemia in the context of chronic kidney disease and is not receiving dialysis. Kidney transplant recipients are included in this population. The appropriate management step depends on the outcome of the preceding treatment line and the clinical reasons that further use of that therapy is no longer appropriate.
A trial of HIF-PHI therapy was undertaken for ESA hyporesponsiveness. The target for that line — a desired erythropoietic response (a rise in hemoglobin) within 3–4 months, monitored at 2–4 weeks after initiation and every 4 weeks thereafter — was not achieved. This failure to reach the target hemoglobin rise is the criterion that escalates management to the current protocol.
When ESA or HIF-PHI therapy has been ineffective or is harmful, a specific transfusion-based strategy forms part of a comprehensive management plan. Decisions are guided by symptoms and signs attributable to anemia rather than by a fixed hemoglobin threshold. Additional considerations apply for patients who are candidates for kidney transplantation. The complete structured regimen and its decision points are available via the link below.
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) 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.
In people with anemia and CKD eligible for organ transplantation, avoid, when possible, RBC transfusions to minimize the risk of allosensitization.
In people with CKD not receiving dialysis, including kidney transplant recipients and children, the selection of Hb concentration at which ESA therapy is initiated should consider the presence of symptoms attributable to anemia, the potential benefits of higher Hb concentration, and the potential harms of RBC transfusions or ESA therapy (2D).
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