Abstract
Anemia is a frequent complication during the late stages of chronic kidney disease, reaching an almost universal prevalence among those with end stage kidney disease. There is a clear association between anemia and an increased risk for decline in the estimated glomerular filtration rate, cardiovascular events, and all-cause mortality. The main mechanisms for the development of anemia related to chronic kidney disease are a relative erythropoietin deficiency and disordered iron homeostasis related to chronic inflammation. Recent improvements in the understanding of the pathophysiology of anemia in chronic kidney disease have advanced the diagnosis and treatment of anemia in chronic kidney disease. While the cornerstone of the diagnosis of anemia related to chronic kidney disease remains excluding other etiologies of anemia, newer diagnostic resources include population-informed cutoffs for traditional measures of iron storage as well as evolving diagnostics of the reticulocyte hemoglobin index and percent hypochromic red blood cells in plasma. Intravenous iron has emerged as a novel tool for both the diagnosis and treatment of disordered iron homeostasis in the anemia of chronic kidney disease. Outside of iron replacement, the treatment of the anemia of chronic kidney disease has traditionally relied on erythropoiesis stimulating agents. A newer class of medications, the Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitors, are an emerging therapy that work by stimulating the transcription of the erythropoietin gene in the Kidney and Liver. These agents are oral therapy, unlike erythropoiesis-stimulating agents, and are used in those who fail to respond to traditional therapy. Additional novel and experimental therapies include SGLT2 inhibitors, inhibitors of hepcidin production, and novel oral and intravenous iron formulations. This review encompasses the highlights of the epidemiology, pathophysiology, and the recent diagnostic and therapeutic advancements for anemia in chronic kidney disease.