Skip to content
Education Use Only
For educational use only — The physician’s written order and the unit protocol always govern
Medical Associates  ·  Department of Nephrology ← Nursing cards  ·  Maintenance Hemodialysis  ·  urinenephrology.org
Dialysis Nursing Reference Card  ·  Maintenance Hemodialysis

N18 — Anemia Labs and Treatment Response

A changing hemoglobin, iron-panel review, or ESA treatment that is not producing the expected response.
Andrew Bland, MD, FACP, FAAP Updated September 2026 Prints on one sheet, front and back
N18 — Anemia Labs and Treatment Response FRONT
Front · at the chair

When: A changing hemoglobin, iron-panel review, or ESA treatment that is not producing the expected response.

Do this

  1. Compare hemoglobin with prior values and the active ESA/iron orders. Record dose changes, missed doses, hospitalization, transfusion, and visible or suspected blood loss.
  2. Read ferritin and TSAT together. Record recent IV iron and collect samples according to the unit protocol, before that session's iron when ordered [1].
  3. Ask about fatigue, dyspnea, chest pain, prolonged access-site bleeding, dark stools, infection symptoms, and poor intake.
  4. If hemoglobin remains low despite increasing ESA, bring the trend and administration record for cause-based review, rather than assuming the dose is simply too low [1].

Call / escalate

  • Chest pain, dyspnea at rest, syncope, hemodynamic instability, or active major bleeding: urgent assessment regardless of the hemoglobin number.
  • An unexpected hemoglobin fall, rapid rise, protocol hold threshold, poor response, active infection, or a discrepant iron panel: notify the prescriber under the unit protocol.

Don't

  • Do not independently increase ESA/iron, order transfusion, or aim to normalize hemoglobin.
  • Do not interpret a high ferritin as proof that iron is available for erythropoiesis. Check TSAT and clinical context [1].
N18 — Anemia Labs and Treatment Response BACK
Back · why, and the evidence

Why

  • KDIGO 2026 distinguishes systemic iron deficiency from iron-restricted erythropoiesis: iron can be present in storage while insufficiently available to developing red cells [1].
  • Blood loss, inflammation, iron restriction, and other reversible causes can blunt ESA response. Repeated dose escalation without evaluation misses the cause [1].
  • This is the laboratory-review card. N10 covers medication administration, product-specific precautions, and hold/report rules; the signed order and local protocol govern.

Bring this to the review

Hemoglobin trend with dates; ferritin/TSAT and iron timing; ESA/iron doses actually given; bleeding/infection symptoms; BP; admissions/transfusions; the decision or repeat test needed.

Go deeper

References

  1. KDIGO 2026 Anemia in CKD guideline. PMID: 41485812
  2. KDIGO 2026 Anemia guideline full text.

Adapted from the linked Clinical Mastery reviews; updated September 27, 2026. For education; the physician's written order and the unit protocol always govern.