Erythropoiesis-stimulating agents (ESAs) like erythropoietin (EPO) are integral for managing anemia in chronic kidney disease (CKD). The recommended initial EPO dosing varies based on the route of administration and the patient’s clinical situation.
For subcutaneous (SC) administration, start with a dose ranging from 50 to 100 U/kg, given three times weekly. For intravenous (IV) administration, apply a similar dosing regimen, and adjust maintenance doses based on hemoglobin (Hb) levels and response.
Aim for a target Hb concentration of 10-11.5 g/dL, and avoid rapid increases to mitigate the risk of adverse cardiovascular events. Adjust doses every 4 weeks, increasing by 25% if Hb rises less than 1 g/dL, or decreasing by 25% if Hb rises more than 1 g/dL within 2 weeks. Monitor ferritin and transferrin saturation (TSAT) to ensure adequate iron stores, as iron deficiency can blunt EPO responsiveness. Maintain ferritin levels > 200 ng/mL and TSAT > 20%.
| Population | Route of Administration | Initial Dose | Dose Adjustment Guidelines |
|---|---|---|---|
| Adults | SUBQ / IV | 50–100 units/kg, 3 times weekly |
Use the lowest dose sufficient to decrease the need for RBC transfusions. Do not exceed Hgb of 11 g/dL (patients on dialysis) or 10 g/dL (patients not on dialysis). If Hgb increases by >1.0 g/dL in 2 weeks, decrease dose by 25%. If Hgb increases by <1.0 g/dL after 4 weeks of therapy (with adequate iron stores), increase dose by 25%. Do not increase the dose more frequently than every 4 weeks. |
| Children (1 month–16 years) | SUBQ / IV | 50 units/kg, 3 times weekly |
Use the lowest dose sufficient to decrease the need for RBC transfusions. Do not exceed Hgb of 12 g/dL. If Hgb increases by >1.0 g/dL in 2 weeks, decrease dose by 25%. If Hgb increases by <1.0 g/dL after 4 weeks of therapy (with adequate iron stores), increase dose by 25%. Do not increase the dose more frequently than every 4 weeks. |
REFERENCES
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Shahab MH, Saifullah Khan S. Erythropoietin Administration for Anemia Due to Chronic Kidney Disease - Subcutaneous OR Intravenous, What Do We Know So Far? Cureus. 2020 Sep 10;12(9):e10358. Available at: https://pubmed.ncbi.nlm.nih.gov/33062481
KDOQI; National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease [published correction appears in Am J Kidney Dis. 2006 Sep;48(3):518]. Am J Kidney Dis. 2006;47(5 Suppl 3):S11-S145. Available at: https://pubmed.ncbi.nlm.nih.gov/16678659
Singh AK, Szczech L, Tang KL, et al. Correction of anemia with epoetin alfa in chronic kidney disease. N Engl J Med. 2006;355(20):2085-2098. Available at: https://pubmed.ncbi.nlm.nih.gov/17108343
KDOQI Clinical Practice Guideline for Anemia in CKD. Available at: https://www.kidney.org/professionals/guidelines/guidelines_commentaries/anemia