Erythropoiesis-stimulating agent hyporesponsiveness: A practical approach
| Cause | Test | Course of action |
|---|---|---|
| Easily correctable causesx | ||
| Iron deficiency | Iron studies | If low, replenish |
| Vitamin B12 deficiency | Vitamin B12 level | If low, replenish |
| Folate deficiency | Folate level | If low, replenish |
| Hypothyroidism | Thyroid-stimulating hormone level | Manage hypothyroidism |
| ACEi/ARB-induced anemia | ACEi or ARB level | Stop ACEi or ARB |
| Potentially correctable causes | ||
| Infection and inflammation | Serum C-reactive protein level | If elevated, check for and treat infection or inflammation |
| Hyperparathyroidism | Parathyroid hormone level | Manage hyperparathyroidism |
| Underdialysis | Kt/V | Improve dialysis efficiency |
| Blood loss or hemolysis | Reticulocyte count (look for high value) | Endoscopy, colonoscopy, hemolysis screen |
| Bone marrow disorder, pure red-cell aplasia | Reticulocyte count (look for low value) | Check anti-ESA antibodies, parvovirus polymerase chain reaction, consider bone marrow biopsy |
| Noncorrectable causes | ||
| Hemoglobinopathies | Serum protein electrophoresis | Hematology referral |
| Bone marrow disorders | Bone marrow biopsy | Hematology referral |
ACEi = angiotensin-converting enzyme inhibitor, ARB = angiotensin II receptor blocker, Kt/V = dialyzer clearance of urea times dialysis time, divided by volume of distribution of urea