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Anaemia in chronic kidney disease | CION Cancer Clinics
Kidney disease lowers haemoglobin mainly because damaged kidneys make less erythropoietin (EPO), the hormone that tells the bone marrow to make red cells. Low iron, hidden bleeding and inflammation often add to it. Treatment usually means iron first, then EPO-type medicine if needed, aiming to ease symptoms rather than reach a normal level. This page explains the causes, the tests and what your report can and cannot show. At CION Cancer Clinics, our haematologist reviews abnormal blood reports with you, orders only the tests that answer your question and explains each result plainly.
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Medically reviewed by Dr. Basudev PokhrelConsultant Haematologist · last reviewed September 2026, next review due September 2027
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On this page
- Why does kidney disease lower your haemoglobin?
- What else pulls haemoglobin down when the kidneys are weak?
- How will your doctor check it?
- How is anaemia in kidney disease treated?
- What do the words on your report mean?
- What do families often believe, and what is true?
- Common questions about anaemia in kidney disease
The short answer
Why does kidney disease lower your haemoglobin?
Healthy kidneys make a hormone called erythropoietin, often written EPO. It tells the bone marrow to make red blood cells. When the kidneys are damaged, they make less of it, so the marrow makes fewer red cells and your haemoglobin slowly falls.
What anaemia means here
Anaemia means a low haemoglobin, the part of the red cell that carries oxygen. In kidney disease it usually creeps in slowly. Many people put the tiredness down to age, work or the kidney problem itself. It tends to be more common, and more marked, as kidney function falls further, and it is very common in people on dialysis.
Why it is rarely only one cause
A shortage of EPO is the main reason, but it is seldom the only one. Low iron stores, small amounts of blood loss, long-standing inflammation and a shortage of vitamin B12 or folate often add to it. This matters, because each cause is treated differently. Giving EPO injections to someone who is short of iron does very little.
What it can feel like
Tiredness that sleep does not fix. Breathlessness on the stairs. Feeling cold, a poor appetite, trouble concentrating, and a pale face or palms. Some people notice nothing at all until a blood test shows it.
A low haemoglobin in someone with kidney disease still needs checking. Do not assume the kidneys explain it until your doctor has looked for the other causes.More than one reason
What else pulls haemoglobin down when the kidneys are weak?
Your doctor looks for all of these, because fixing one and missing another leaves the haemoglobin low.
Too little EPO
The damaged kidney cannot send a strong enough signal to the marrow. The marrow itself is usually healthy. It is simply not being asked to work hard enough.
Low iron
The marrow needs iron to build each red cell. Iron may be low in the body, or present but locked away and hard to use.
Often linked to
- Poor appetite and a limited diet
- Blood left in dialysis lines
- Frequent blood tests
Hidden bleeding
People with kidney disease bleed a little more easily, especially from the stomach and gut. Slow bleeding may not be visible, but it drains iron over months.
Inflammation and vitamins
Long-standing inflammation or infection makes the marrow respond less well. Low vitamin B12 or folate slows red cell production too.
Your doctor may also check the thyroid, because an underactive thyroid can lower haemoglobin.Not sure whether this applies to you?
Ask an oncologistFinding the cause
How will your doctor check it?
A full blood count
This measures haemoglobin and the size of your red cells. Small cells point towards iron. Large cells point towards B12 or folate. Normal-sized cells fit a shortage of EPO.
Iron studies
Ferritin and transferrin saturation show how much iron is stored and how much is actually reaching the marrow. Both are needed, because inflammation can make ferritin look higher than it really is.
B12, folate and a reticulocyte count
These show whether vitamins are short and whether the marrow is making new red cells at a normal pace. A stool test for hidden blood may be added.
Reading it with your kidney results
Your nephrologist or haematologist reads all of this beside your kidney function tests. If the picture does not fit kidney disease, they look further before starting any treatment.
Treatment
How is anaemia in kidney disease treated?
Treatment usually starts with iron, then adds a medicine that does the job of EPO if haemoglobin stays low. The aim is to ease symptoms and cut the need for blood transfusions, not to push haemoglobin all the way to a normal level.
Iron first
Iron may be given as tablets or, more often in later kidney disease and on dialysis, through a drip. Iron through a vein works faster and avoids the stomach upset that tablets can cause. Your team decides which form and how often.
EPO-type injections
These are man-made versions of the hormone your kidneys no longer make enough of. Your report or prescription may call them ESAs. They are given under the skin or into the dialysis line. Newer tablet medicines that help the body make its own EPO are used in some cases.
Who they do not suit
Aiming too high raises the risk of stroke, clots and high blood pressure. That is why the target is set below normal on purpose. EPO-type medicines need extra care in people with active cancer, a recent stroke or blood pressure that is not controlled. Transfusion is kept for severe or sudden falls, partly because it can make a future kidney transplant match harder to find.
Never change, skip or stop an iron or EPO dose on your own. If you think it is not working, ask your treating team.Leave a number, we will call you
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On your report
What do the words on your report mean?
- Hb or haemoglobin
- The oxygen-carrying part of your red cells. A single low result is read alongside your symptoms and repeat tests.
- Ferritin
- A measure of stored iron. It can read falsely high when there is inflammation, so it is never read alone.
- TSAT
- Transferrin saturation. It shows how much iron is actually on its way to the marrow.
- eGFR
- An estimate of how well your kidneys filter the blood. Lower numbers mean less kidney function.
- ESA
- Short for a medicine that stimulates red cell production, the family that EPO injections belong to.
- Reticulocytes
- Young red cells. A low count means the marrow is not making many new cells.
Commonly believed
What do families often believe, and what is true?
"Eating more spinach and dates will fix it."
A good diet helps, but food cannot replace a hormone the kidneys no longer make. Some iron-rich foods are also high in potassium, which can be unsafe in kidney disease. Ask your dietitian before changing what you eat.
"Once the haemoglobin is normal, we can stop the injections."
If the kidneys still make too little EPO, haemoglobin usually falls again when the medicine stops. Your team adjusts the plan based on repeat tests. Only they should decide to reduce or stop it.
"A blood transfusion is the quickest and safest answer."
A transfusion works fast, but the effect fades and it carries its own risks. It can also make a kidney match harder later. It is kept for when the haemoglobin is very low or you are unwell.
"Low haemoglobin in kidney disease means blood cancer."
In most people it is explained by the kidneys, iron or blood loss. A haematologist is asked to look when the counts do not fit that picture, such as when white cells or platelets are also abnormal. That referral is a check, not a diagnosis.
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When not to wait for the next clinic visit
Go to the nearest emergency department or call 108 the same day if you have chest pain, severe breathlessness at rest, fainting, black or bloody stools, or vomiting blood. The same applies to a sudden severe headache or weakness on one side of the body while on EPO-type medicine. Tell the team you have kidney disease and which medicines you take. Do not take an extra dose of anything first.
Questions we are asked
Common questions about anaemia in kidney disease
What haemoglobin level counts as anaemia?
The WHO sets a lower cut-off for adult women who are not pregnant than for adult men, and your report prints the range your laboratory uses. Ranges differ a little between laboratories, and one result is read with your symptoms and repeat tests. In kidney disease, your treatment target is set by your team and sits below the normal range on purpose.
Does everyone with kidney disease get anaemia?
No. It is uncommon in mild kidney disease and becomes more common as kidney function falls. Most people on dialysis have it at some point. People with diabetes and kidney disease tend to develop it earlier. Regular blood counts catch it before symptoms become troublesome.
Are EPO injections safe for a long time?
Many people use them for years under supervision. The main risks are raised blood pressure, clots and stroke, which is why the dose is adjusted to keep haemoglobin in a target range rather than as high as possible. Your blood pressure and counts are checked regularly while you are on them.
Why is my haemoglobin not rising on EPO?
The commonest reason is low iron. Others include infection, inflammation, hidden bleeding, low B12 or folate, and poorly controlled dialysis. Occasionally a marrow problem is the cause, and a haematologist may be asked to review. Do not raise the dose yourself. Tell your team so they can look for the reason.
Can iron through a drip cause a reaction?
Reactions are uncommon, and the modern forms are much safer than older ones. You are watched during the drip and for a short while after. Tell the nurse at once if you feel itching, breathless, dizzy or have chest tightness. Mention any past reaction to iron before it starts.
Will a kidney transplant fix the anaemia?
Often it improves, because a working transplant starts making EPO again. It does not always settle fully, and some anti-rejection medicines can lower counts. Blood tests continue after a transplant, and iron or other treatment may still be needed for a while.
When should I see a haematologist rather than only my kidney doctor?
Usually when the anaemia is out of proportion to your kidney function, does not respond to iron and EPO, or comes with abnormal white cells or platelets. At CION, Dr. Basudev Pokhrel reviews such reports and works alongside your nephrologist rather than replacing them.
What can this page not tell me?
It cannot tell you why your own haemoglobin is low, what target is right for you, or which medicine you need. Those depend on your kidney function, iron results, other illnesses and plans such as a transplant. Bring your recent reports and your medicine list to your doctor, and ask them to explain each result.
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Dr. Basudev Pokhrel reviews blood counts, transfusion needs and blood disorders, and works with the CION tumour board on blood cancers.
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Sources
- WHO — Anaemia
- NICE — Chronic kidney disease: assessment and management of anaemia (NG203)
- NHS — Chronic kidney disease
- NHLBI — Anemia
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
Anaemia in Liver DiseaseHow liver problems lower haemoglobin in different waysDiabetes and Blood Count ChangesDiabetes and kidney disease often come togetherDrug-Induced Low CountsWhen a medicine is the reason counts fallBlood Disorders Caused by Other Illness or DrugsThe full guide to blood changes caused by other conditions
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Have a blood report that does not add up?
Share your recent blood counts and kidney results. Our haematology team will look at them with you and explain the next step. One helpline serves every CION centre.