How is anemia managed in children with chronic kidney disease (CKD)?

Updated: Jul 21, 2020
  • Author: Sanjeev Gulati, MD, MBBS, DNB(Peds), DM, DNB(Neph), FIPN(Australia), FICN, FRCPC(Canada); Chief Editor: Craig B Langman, MD  more...
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The presence of anemia 1 month after dialysis initiation is associated with an increased risk of prolonged hospitalization and death in pediatric patients. The beneficial effects of treating anemia with erythropoietin in patients who are dialysis-dependent include the improvement of cardiac status, exercise capacity, cognitive function, and quality of life. Recombinant human erythropoietin (rHuEPO) has been used for chronic kidney disease (CKD)–associated anemia since 1986. Based on the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, the recommended target hemoglobin-to-hematocrit (Hgb/Hct) ratio is 11-12 g/dL / 33-36%. [20]

Iron supplementation is essential to ensure an adequate response to erythropoietin. This is targeted to maintain a transferrin saturation level of 20% or higher and serum ferritin level of 100 ng/dL or higher in children with chronic kidney disease. The pediatric dose of oral iron is 2-3 mg/kg/d divided in 2-3 doses.

Oral iron is best absorbed when ingested without food or other medications. The percentage of iron absorbed orally is affected by the iron salt form (eg, ferrous sulfate, ferrous gluconate), the amount administered, the dosing regimen, and size of iron stores. Foods that enhance iron absorption include protein from meat and vitamin C. Foods that may inhibit absorption include unrefined grains, soy, coffee, cocoa, herb teas, red wine, calcium, and some proteins (eg, soy, eggs, casein).

Intravenous iron may be necessary for maintenance treatment of anemia associated with CKD. Intravenous iron products that are FDA-approved for use in children include iron dextran (DexFerrum, InFed), iron sucrose (Venofer), and ferric gluconate (Ferrlecit).

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