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Anemia in children with chronic kidney disease

Nature Reviews Nephrology volume 7, pages 635–641 (2011)Cite this article

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Abstract

Anemia is a common comorbidity in children with chronic kidney disease (CKD). This condition is associated with multiple adverse clinical consequences and its management is a core component of nephrology care. Increased morbidity and mortality, increased risk of cardiovascular disease and decreased quality of life have been associated with anemia of CKD in children. Although numerous complex factors interact in the development of this anemia, erythropoietin deficiency and iron dysregulation (including iron deficiency and iron-restricted erythropoiesis) are the primary causes. In addition to iron supplementation, erythropoietin-stimulating agents (ESAs) can effectively treat this anemia, but there are important differences in ESA dose requirements between children and adults. Also, hyporesponsiveness to ESA therapy is a common problem in children with CKD. Although escalating ESA doses to target increased hemoglobin values in adults has been associated with adverse outcomes, no studies have demonstrated this association in children. The question of appropriate target hemoglobin levels in children, and the approach by which to achieve these levels, remains under debate. Randomized, controlled studies are needed to evaluate whether normalization of hemoglobin concentrations is beneficial to children, and whether this practice is associated with increased risks.

Key Points

  • Anemia, in particular anemia that is poorly responsive to treatment, is very common in children with chronic kidney disease (CKD) and end-stage renal disease

  • Adverse effects of anemia in this population include the development of left ventricular hypertrophy, increased risk of hospitalization and mortality, progression of kidney disease and decreased quality of life

  • Iron-restricted erythropoiesis has a key role in the development of CKD-associated anemia and is mediated in part by inflammation and the iron-regulatory protein hepcidin

  • Erythropoietin-stimulating agents (ESAs) and iron supplementation remain the mainstays of therapy for the anemia of CKD in children, with children demonstrating higher ESA dosing requirements than adults

  • The question of the appropriate target hemoglobin level in children remains under debate, and randomized, controlled studies are needed in children with CKD to evaluate the risks and benefits of targeting normalization of hemoglobin levels

  • Regarding the safety and efficacy of escalating ESA doses, the identification of pathways beyond erythropoietin deficiency is needed to develop other safe, nontoxic clinical interventions to treat the anemia of CKD

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Authors and Affiliations

  1. Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Room 3064, Baltimore, 21287, MD, USA

    Meredith A. Atkinson

  2. Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, 19104, PA, USA

    Susan L. Furth

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M. A. Atkinson and S. L. Furth contributed equally to discussion of content for the article, researching data to include in the manuscript and reviewing and editing of the manuscript before submission.

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Correspondence to Meredith A. Atkinson.

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Atkinson, M., Furth, S. Anemia in children with chronic kidney disease. Nat Rev Nephrol 7, 635–641 (2011). https://doi.org/10.1038/nrneph.2011.115

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