Managing Anaemia in Dialysis: Why You Feel Tired All the Time

What Is Anaemia in Dialysis Patients?

The WHO defines anaemia as haemoglobin below 13 g/dL in men and below 12 g/dL in women. CKD patients are twice as likely to develop anaemia compared to those without kidney disease. Anaemia prevalence exceeds 50% in advanced CKD stages G4 and G5, rising sharply as kidney function declines ^[1]. Among dialysis patients specifically, anaemia prevalence reaches 94.7%, making it near-universal in this population. Half of all incident dialysis patients have haemoglobin levels below 10 g/dL, at which point fatigue and cardiovascular strain become clinically significant. The causes are multifactorial; EPO deficiency, iron loss, shortened red cell lifespan, high hepcidin levels, and systemic inflammation all contribute. No single cause fully explains it, which is why anaemia in dialysis patients requires a structured, stepwise approach to management.

5 Causes of Anaemia in Dialysis Patients

Anaemia in CKD is frequently multifactorial; common causes include relative EPO deficiency, shortened red blood cell survival, iron deficiency, blood loss during haemodialysis, uremic toxin-induced bone marrow inhibition, and systemic inflammation. In most Indian dialysis patients, several of these mechanisms are active simultaneously.
Here are five causes for anaemia that dialysis patients should know:

1. EPO Deficiency

Erythropoietin deficiency is a hallmark of chronic kidney disease; EPO is produced by peritubular interstitial cells in the renal cortex, and its absence leads to programmed apoptosis of erythroid precursors in the bone marrow. When those peritubular cells are destroyed by kidney disease, the signal to produce red blood cells from bone marrow disappears entirely.

2. Iron Loss and Hepcidin Dysregulation

Increased hepcidin levels in CKD degrade ferroportin, the known cellular iron exporter, trapping iron in storage sites and making it unavailable for haemoglobin production. This condition, now termed iron-restricted erythropoiesis by KDIGO 2026, does not respond to oral iron supplements alone and requires intravenous iron therapy.

3. Blood Loss During Dialysis

Blood loss from haemodialysis, bleeding due to dysfunctional platelets, and frequent phlebotomy for blood testing are all direct contributors to anaemia in dialysis patients. In India, where twice-weekly dialysis is the norm, cumulative session-by-session blood loss carries more clinical weight than in thrice-weekly protocols.

4. Shortened Red Blood Cell Lifespan

Normal red blood cell lifespan is typically 120 days, but in CKD it may shorten to as little as 60 days due to uremic toxins that increase oxidative stress and accelerate red cell destruction. This shortened lifespan has been confirmed in radioisotope-labelling studies, with uremia identified as a key contributing factor.

5. Nutritional Deficiencies

Vitamin B12 and folate deficiencies due to dialysate losses or poor appetite contribute directly to anaemia; routine supplementation of water-soluble vitamins is standard in haemodialysis, though micronutrients can still be lost during sessions. The Indian Society of Nephrology recommends evaluation of red cell indices, including MCV, and a peripheral smear, as macrocytosis may specifically indicate B12 or folate deficiency in CKD patients.

Next, let’s understand the symptoms and burden associated with dialysis patients and how they affect individuals’ well-being.

Symptoms and Burden of Dialysis Anaemia

Anaemia in dialysis patients does not just lower your haemoglobin; it is consistently associated with greater mortality, hospitalisation, cardiovascular events, and CKD progression, with risk increasing directly alongside anaemia severity.

• Fatigue and dialysis fatigue: Fatigue is the most prevalent symptom among the causes of anaemia in dialysis patients, reported in 70% of those on dialysis across multiple studies ^[2]. When anaemia is left untreated, reduced oxygen delivery to tissues makes post-dialysis exhaustion significantly worse than it should be.
• Cardiovascular strain: One of the less-discussed dialysis side effects, anaemia causes compensatory increases in cardiac output and left ventricular hypertrophy, which can ultimately progress to cardiac failure. This risk is especially significant in Indian dialysis patients, where cardiovascular disease is already the leading cause of chronic kidney disease (CKD) mortality.
• Mortality risk by haemoglobin level: In anaemia in CKD, dialysis patients with haemoglobin below 10 g/dL have a 56% higher all-cause mortality risk than those above 12 g/dL. Risk rises measurably with each further drop in haemoglobin level.
• Cognitive and sleep consequences: Anaemia in CKD patients is linked to cognitive function disorders, sleep disturbance, and impaired immune function. The burden of tiredness in anaemic dialysis patients is comparable in quality-of-life impact to conditions such as diabetes or certain cancers.
• Missed dialysis sessions: Without consistent anaemia management in dialysis patients, depressive symptoms worsened by anaemia-driven fatigue are associated with non-adherence to medications and dialysis attendance. In India, where most patients travel considerable distances to a dialysis clinic twice weekly, untreated anaemia is a direct barrier to consistent care.

Now, let’s understand how anaemia is diagnosed for CKD patients.

How Anaemia Is Diagnosed in CKD Patients

Diagnosing anaemia in dialysis patients requires a structured, stepwise approach, starting with a minimum core panel and expanding the workup when initial results do not explain the cause.

Here are some of the diagnosis parameters for CKD patients:

• Anaemia management in dialysis patients begins with a complete blood count, reticulocytes, ferritin, and TSAT, which should be measured every 3 months. These four tests simultaneously assess red cell production and iron availability.
• Low ferritin confirms iron deficiency, but high ferritin does not rule it out in CKD or with chronic inflammation. Iron therapy in haemodialysis patients is considered when ferritin is at or below 500 ng/mL and TSAT at or below 30%.
• If initial tests are inconclusive, an expanded panel, including a blood smear, CRP, vitamin B12, folate, liver function tests, and thyroid-stimulating hormone, should follow. In India, B12 and folate testing carries added weight, given higher rates of dietary restriction and malnutrition.
• The 2026 guideline replaced “functional iron deficiency” with “iron-restricted erythropoiesis.” This condition, driven by elevated hepcidin, does not respond to oral iron; it requires intravenous therapy and directly worsens dialysis fatigue when left unaddressed.
• Haemoglobin, ferritin, and TSAT should be tested every one to three months for haemodialysis patients on iron therapy, more frequently after dose changes or during illness. Without this, anaemia worsens silently before your care team can act.

Also read: Vascular Access Care: Protecting Your Dialysis “Lifeline”.

Anaemia Management in Dialysis Patients

Anaemia management in dialysis patients follows a clear evidence-based ladder; iron correction comes first, followed by stimulating red blood cell production, with the approach adjusted based on each patient’s haemoglobin trend and response.

• In haemodialysis patients, IV iron is strongly preferred over oral iron, and iron therapy should be suspended during any active systemic infection. Oral iron is largely ineffective in dialysis patients because elevated hepcidin blocks intestinal absorption, making tablets an unreliable option for most patients.
• Erythropoiesis-stimulating therapy is considered when haemoglobin falls to or below 9-10 g/dL, with the maintenance target kept below 11.5 g/dL per KDIGO 2026. Pushing haemoglobin higher than this threshold increases cardiovascular risk, a relevant concern given India’s high burden of cardiac disease in dialysis patients.
• Treatment response should be reviewed at least every 4 weeks; a rapid rise in haemoglobin of more than 1 g/dL within 2 weeks requires an immediate dose reduction of 25–50% ^[3]. Irregular follow-up, common in Indian dialysis settings, makes this a frequently missed safety step.
• A newer class of oral agents stimulates the body’s own EPO production while reducing hepcidin levels, improving iron availability without the need for injections. These options are now available in select Indian dialysis centres and suit patients where injection-based therapy presents access or cost barriers.
• Routine transfusion in dialysis patients is actively discouraged; it raises sensitisation risk and directly narrows future transplant eligibility. Every unnecessary transfusion is a decision that affects long-term options, not just immediate haemoglobin levels.