Anemia Diagnostic Tests Infrequent, Linked to Low Treatment Rates in CKD

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Diagnostic tests for anemia etiology are infrequently ordered, leading to a significant majority of patients with CKD receiving inadequate treatment.

Diagnostic investigations for the etiology of anemia were inadequately ordered, leading to a significant majority of anemic patients with advanced stages of chronic kidney disease (CKD) lacking adequate treatment, according to new research.1

The single-center, observational, retrospective study, presented at the 61st European Renal Association (ERA) Congress in Stockholm, Sweden revealed more than half of patients with anemia had not received any form of treatment for the most common blood disorder.

“This study has shown that diagnostic tests for etiology of anemia were insufficiently ordered,” wrote the investigative team, led by Mustafa Arici, MD, a professor of medicine in the department of nephrology at Hacettepe University. “It was also found that a significant majority of anemic patients who underwent etiological evaluation were not even adequately treated.”

Anemia is commonly identified in the early stages of chronic kidney disease (CKD), and its severity can have a significant impact on a patient’s quality of life over the progression of kidney disease.2

Some evidence has shown early identification and immediate treatment of anemia, by normalization of hemoglobin and iron levels, in patients with CKD, is linked to reduced renal disease progression and improved quality of life, including improved energy and cognitive function.3

Noting the crucial nature of early diagnosis of anemia in CKD, Arici and colleagues sought to evaluate the frequency of anemia in different stages of CKD, particularly in patients with Stage 3 and more advanced stages of the disease.1 The team aimed to assess the effectiveness of diagnostic approaches, iron parameters in anemia management, and the effect of anemia on patient survival rates.

In particular, they wanted to obtain ‘real-world’ data to help pilot changes in clinical practice and correct errors or deficiencies in managing the blood disorder.

The single-center, observational, descriptive, retrospective study investigated these factors among 1321 outpatients with anemia at Stage 3A and advanced CKD who were admitted to the Hacettepe University Faculty of Medicine Nephrology Clinic between 2014 and 2018.

Diagnostic analysis for anemia and therapeutic interventions included the administration of iron, folic acid, vitamin B12, and erythropoiesis-stimulating agents (ESA). Investigators also measured the long-term yield of diagnostic and therapeutic approaches and their effects on survival.

Measured outcomes included the effect of anemia severity and improvement in anemia symptoms on survival rates. An electronic health system was used to collect data on demographics, CKD etiologies and stages, anemia severity, and comorbid diseases.

Upon analysis, ferritin was the most performed test for the etiology of anemia (76.4%). On the other hand, request rates of tests, including B12, folic acid, transferrin saturation, and reticulocyte, were each below 20%.

According to the findings, more than half (59.4%) of the patients with anemia did not receive any form of treatment. This remained true even among those whose ferritin level was checked, and the level was <100 µg/dL—only 41.4% were provided iron treatment.

Notably, when the clinical follow-period was extended, anemia treatment was applied correctly, and target values were achieved more often (P <.001).

Mortality rates showed more than one-third of patients (34.8%) died during the follow-up period. The overall survival rate in patients who experienced anemia improvement, and thus improved survival, was 79.8%, compared with 62.8% in patients who did not experience anemia improvement (P = .002).

In an examination of the correlation between survival status and anemia severity among those with non-dialysis-dependent CKD Stage 3–5 group, Arici and colleagues identified a statistically significant survival difference between the hemoglobin level of 10–11.9 g/dL with the group <10 g/dL (P = .004).

“In conclusion, we recommend an optimal evaluation of CKD patients with anemia and initiating treatment as early as possible,” they added.


  1. Çiğdem Kara Kurak, Sarenur Karlık, Mutlu Hayran, Güldehan Haberal, Arda Erdut, Hasan Hacı Yeter, Tolga Yildirim, Şeref Rahmi Yilmaz, Bulent Altun, Yunus Erdem, Mustafa Arici, #511 Inadequate diagnostic investigations and low treatment rates in CKD anemia: an inertia that can only change with long-term follow-up. Presented at the 61st European Renal Association Congress. Stockholm, Sweden. May 23-26, 2024.
  2. Shaikh H, Hashmi MF, Aeddula NR. Anemia of Chronic Renal Disease. [Updated 2023 Feb 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:
  3. Shiferaw WS, Akalu TY, Aynalem YA. Risk Factors for Anemia in Patients with Chronic Renal Failure: A Systematic Review and Meta-Analysis. Ethiop J Health Sci. 2020;30(5):829-842. doi:10.4314/ejhs.v30i5.23