Erythropoiesis-stimulating agent hyporesponsiveness: A practical approach

CauseTestCourse of action
Easily correctable causesx
Iron deficiencyIron studiesIf low, replenish
Vitamin B12 deficiencyVitamin B12 levelIf low, replenish
Folate deficiencyFolate levelIf low, replenish
HypothyroidismThyroid-stimulating hormone levelManage hypothyroidism
ACEi/ARB-induced anemiaACEi or ARB levelStop ACEi or ARB
Potentially correctable causes
Infection and inflammationSerum C-reactive protein levelIf elevated, check for and treat infection or inflammation
HyperparathyroidismParathyroid hormone levelManage hyperparathyroidism
UnderdialysisKt/VImprove dialysis efficiency
Blood loss or hemolysisReticulocyte count (look for high value)Endoscopy, colonoscopy, hemolysis screen
Bone marrow disorder, pure red-cell aplasiaReticulocyte count (look for low value)Check anti-ESA antibodies, parvovirus polymerase chain reaction, consider bone marrow biopsy
Noncorrectable causes
HemoglobinopathiesSerum protein electrophoresisHematology referral
Bone marrow disordersBone marrow biopsyHematology 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