Managing anemia due to chronic kidney disease (CKD) can be a balancing act.

Is a more steady experience possible?

Many patients with CKD are burdened by anemia. And, while treatments are available, unmet needs remain.1,2

Conversations with experts

Moderated by

Anjay Rastogi


In this series, experts discuss the ongoing challenges for patients and physicians managing anemia due to CKD. Watch these exciting conversations, moderated by Anjay Rastogi, MD, PhD of UCLA.

Click on the video images to watch highlights or the blue buttons to watch the full conversations.

How does anemia due to CKD impact the patient?

Anemia is more than fatigue—its manifestations can have a serious, far‑reaching, and long‑term effect on patients3

Anemia due to CKD (Stages 3-5):

Occurs in4

About 25% of patients with Stage 3 CKD and greater than 50% of patients with Stage 5 CKD

50% of older Medicare patients (ages 65‑85) with Stages 3‑5 CKD

Can make everyday tasks challenging like

cooking, walking, light housework, or even walking up stairs2,5,6

May result in


Can be associated with

an increased risk of disease progression, hospitalization, and death8-10

In a 3-year study, the annual hospitalization rates were significantly higher in Stage 3 CKD patients with anemia compared to those without (N=439)10

In a retrospective study (5% Medicare database), the 2-year mortality rate was ~2.5X greater in patients with anemia due to CKD compared to those without either condition11

Burden of anemia due to CKD

Watch this video to learn about the clinical burden of the disease and how anemia can contribute to worsening of outcomes in CKD patients.

Pathogenesis of
anemia due to CKD12,13

Anemia due to CKD is multifactorial, primarily arising from insufficient synthesis of erythropoietin (EPO), EPO resistance, disordered iron homeostasis, and inflammation.12,13 The current treatment landscape has remained largely unchanged for the past 30 years and consists of iron supplementation, ESAs, and RBC transfusion.14

Click '+' buttons to view treatment guidelines.

Pathogenesis of anemia due to CKD

Hepcidin Due To

Limited Iron
Absorption &

Reduced RBC



The science of the
HIF pathway13,15-18

Hypoxia-inducible factors (HIFs) are gene transcription factors that regulate how the body adapts to hypoxia.19 HIF levels increase in response to hypoxia within cells, which can lead to the endogenous production of EPO.19 The HIF pathway is a new focus for understanding the multifaceted causes of anemia due to CKD.12,19,20

Did you know?

The discovery of the HIF pathway earned a Nobel Prize for Physiology or Medicine in 201921




HIFs are transcription
factors that regulate

Active PHD Enzymes

Inactive PHD Enzymes

HIF-α activity
is regulated
by oxygen
dependent PHD

In hypoxia,
PHD is inactive
and HIF-α is

Stabilized HIF-α
translocates to the
nucleus and
dimerizes with HIF-β

Active PHD Enzymes





In normoxia,
PHD is active and
leads to
the degradation
of HIF-α

Gene Transcription

The active HIF
dimer activates
expression of
genes related to
EPO production,
iron metabolism,
and inflammation



No change



Activation of the HIF pathway
increases iron metabolism
and stimulates production
of EPO physiologically8,20

Pathogenesis of anemia due to CKD

How might the management of anemia due to CKD be impacting your patients and your practice?

While treatments are available for anemia due to CKD, unmet needs remain, and undertreatment continues to be a challenge.22,23

Management options at a glance:
Anemia due to CKD can be effectively managed with the following treatments, per KDIGO guideline recommendations24

oral or intravenous (IV) iron to correct
iron deficiency

erythropoietin-stimulating agents to address low EPO via injection

IV blood transfusions to increase red blood cell count


are a supplemental approach to raise hemoglobin (Hb), but they do not address the pathophysiological cause of anemia due to CKD.8

ESAs are the mainstay of care for certain patients with anemia due to CKD.24

Treatments may present certain hurdles throughout the patient experience, such as:24-28

  • Inconvenient, complex, or painful administration

  • Titration and additional monitoring to stay within Hb targets

  • Risk of infection and other complications

  • Logistical challenges, such as care coordination and transportation to office visits

How can the patient experience be different?

A prospective study found that the majority of non-dialysis-dependent patients with CKD were not treated22
Approximately 70-80% of non-dialysis-dependent patients

across CKD Stages 3-5

72% of non-dialysis-dependent patients

with Hb <10 g/dL
not treated with an ESA

What are some recent trends to consider that could impact the future patient experience?

One recent survey of Medicare Part B patients found telemedicine has increased from 0.1% to 43.5%, before and during COVID-1929

From 2007 to 2017, home dialysis usage increased 127%30

Your anemia

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