Evaluation and management of anemia in children with CKD*

MCV: mean corpuscular volume; CKD: chronic kidney disease; Hb: hemoglobin; ESA: erythropoiesis-stimulating agents.
* This algorithm is intended for children with moderate to severe CKD defined as an estimated glomerular filtration rate <59 mL/min per 1.73 m² and anemia defined as an Hb <2.5th percentile based on the patient's age, sex, and race. Refer to UpToDate topics on the approach to the child with anemia and on definition, epidemiology, etiology, and course of chronic kidney disease in children.
¶ MCV is measured directly by automated blood cell counters and represents the mean value (in femtoliters [fL]) of the volume of individual red blood cells in the blood sample. Normal values for MCV vary based upon age. sex, and race. Refer to UpToDate topics on the approach to the child with anemia.
Δ High reticulocyte count >3% is associated with an increased erythropoietic response to blood loss or hemolysis. Common causes of anemia with a high reticulocyte count include: hemorrhage, autoimmune hemolytic anemia, membranopathies (eg, hereditary spherocytosis), enzymopathies (eg, glucose-6-phosphate dehydrogenase [G6PD] deficiency). hemoglobinopathies (eg, sickle cell disease), and microangiopathic hemolytic anemia (eg, hemolytic uremic syndrome). Refer to UpToDate topic on the approach to the child with anemia.
◊ In some cases, anemia may be due to both CKD and iron deficiency resulting in microcytic anemia (low MCV). In this setting, anemia will persist with normalization of MCV after iron repletion demonstrating the underlying contribution of CKD.
§ Iron deficiency is diagnosed by laboratory testing including measuring serum iron, total iron binding capacity, percent transferrin saturation (TSAT), and serum ferritin. Refer to UpToDate topics on iron deficiency in children and adolescents.
¥ ESAs include recombinant human erythropoietin (rHuEPO) and darbepoetin alfa.