Visual summary
An inadequate response is a reason to investigate the cause, not simply to keep increasing the dose.
Text version
Build a dated timeline
Compare hemoglobin with doses actually administered, dose changes, missed treatments, hospitalizations, transfusions, and bleeding. Distinguish an unexplained new fall from a longstanding pattern before requesting a treatment adjustment.
Read iron studies together
Interpret ferritin and transferrin saturation with inflammation, recent IV iron, and collection timing. High ferritin does not prove iron is available for red-cell production, and one unusual panel may need confirmation.
Look for an explanation
Ask about access bleeding, dark stools, infection, poor intake, fatigue, and dyspnea. Persistent low hemoglobin despite escalating ESA should trigger cause-based review, including iron restriction, blood loss, inflammation, and other diagnoses.
Escalate by the clinical picture
Chest pain, dyspnea at rest, syncope, major bleeding, or instability requires urgent assessment regardless of the reported hemoglobin. A rapid rise, unexpected fall, or protocol hold threshold needs timely prescriber review.
Keep the target individualized
KDIGO 2026 anemia guidance is final. Treatment balances symptoms, transfusion avoidance, and medication risks; do not aim to normalize hemoglobin or independently increase ESA, iron, or transfusion exposure.
Handoff the response question
Bring hemoglobin dates, ferritin and TSAT, iron timing, actual ESA and iron delivery, blood pressure, symptoms, and admissions. State whether the team needs to investigate a cause, adjust therapy, or repeat a test.
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