Anaemia

Treating anaemia by increasing the amount of haemoglobin in the blood helps to restore energy, improve stamina for exercise, and may help improve other problems, such as problems with sexual function.

Iron concentrations are often low in people with kidney disease either because their diet doesn’t contain enough iron, or there’s something wrong with how the body absorbs iron from the food as it is digested. Extra iron is given (either in the form of iron tablets or intravenous iron injections) to provide enough for normal production of red cells and to reverse or lessen the anaemia.

In the past, blood transfusion was the only really effective treatment for renal anaemia, but it had a number of problems:

• Each transfusion could carry a small risk of infection by viruses (eg cytomegalovirus, Epstein-Barr virus, Hepatitis B and C viruses, HIV) in the blood.
• Some people’s immune systems could mistake the cells in the blood transfusion for an ‘invader’ and react by making antibodies to them. This could result in potential difficulties:
  • matching possible future kidney transplants
  • matching blood for further transfusions.
• Patients could have allergic reactions during transfusions.
• Repeated transfusions could lead to iron building up in the body, particularly in the heart and liver, causing damage to these organs.
• Blood transfusions appear to reduce the body’s immunity to infection.

Since 1985 when artificially produced erythropoietin (EPO) became available it has been a very successful treatment for renal anaemia. It replaces the erythropoietin that healthy kidneys would be producing and needs to be given by injections every few days or weeks. In people receiving haemodialysis, the injections are usually given into the machine. In people not on any form of dialysis and those on peritoneal dialysis, the injections are normally given under the skin, like insulin.

Anaemia in people with kidney disease often requires a combination of additional iron (either in the form of iron tablets or intravenous iron injections) and EPO injections. EPO speeds up the production of red blood cells in the bone marrow, but this takes time, so, it can take several weeks for treatment to work.

Side effects are rare but some are important, for example:

• High blood pressure, especially if the haemoglobin (Hb) level rises rapidly, or becomes too high
• Clotting of fistulas used for haemodialysis may be more likely if haemoglobin levels are high
• Heart disease and stroke are more common if treatment is adjusted to increase the haemoglobin level towards normal levels
• Very rarely patients react to EPO, making antibodies that stop it working. The bone marrow stops producing red cells, which results in a condition called “pure red cell aplasia”. This is a very severe anaemia that can only be treated with blood transfusions.

The best level for haemoglobin if you have kidney disease is probably low-normal or a little bit lower than normal. This relieves the symptoms of anaemia without causing complications.

• Don’t hesitate to speak to your kidney specialist or renal unit if you think you may have anaemia or need treatment with iron or EPO – or if you need help with any other aspects of your illness.