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Recomendación 1:
En personas con ERC con una TFG menor a 60 mL/min/1.73m² y anemia, sugerimos investigar la anemia para verificar que sea secundaria a ERC. (Recomendación débil a favor)

BPC 1:
En personas con ERC, el diagnóstico de anemia se define como hemoglobina menor a: 

• 12.0 g/dL en mujeres
• 13.0 g/dL en varones

BPC 2:
En pacientes que residen en lugares a más de 1000 metros sobre el nivel del mar, considere la corrección de los valores de hemoglobina para el diagnóstico de anemia, según los valores de OMS.

BPC 3:
Cuando la TFG es mayor o igual a 60 mL/min/1.73m², pensar que es probable que la anemia se deba a otras causas como deficiencia de ácido fólico o de vitamina B12.

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Recomendación 1:

En personas con ERC y anemia, sugerimos que el diagnóstico de déficit de hierro se realice con alguna de las siguientes pruebas o combinaciones de pruebas:

• La combinación de saturación de transferrina menor del 20% y ferritina sérica menor de 100 microgramos/litro (debiendo cumplir con ambos criterios), o
• El contenido de Hb de reticulocitos (CHr) menor a 29 pg, o
• El porcentaje de glóbulos rojos hipocrómicos (%HRC) mayor al 6%, pero solo si el procesamiento de la muestra de sangre es posible dentro de las 6 horas desde su extracción.
• El contenido de Hb de reticulocitos (CHr) menor a 29 pg , o

(Recomendación débil a favor)

BPC 1:
En personas con ERC, se pueden utilizar las constantes corpusculares (VHCM, CHCM) que se encuentran en el hemograma para evaluar la sospecha de déficit de hierro.

BPC 2:
Realice las pruebas de diagnóstico de déficit de hierro cada 3 meses para personas con ERC que no estén en hemodiálisis crónica, y cada mes para personas con ERC en hemodiálisis crónica.

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Recomendación 1:
Para las personas con ERC que no están recibiendo hemodiálisis crónica, recomendamos administrar una prueba de hierro oral antes de ofrecer la terapia de hierro intravenoso. Si el paciente es intolerante al hierro oral o si la Hb objetivo no se alcanza dentro de los 3 meses de terapia con hierro oral, ofrezca terapia de hierro intravenoso. (Recomendación fuerte a favor)

Recomendación 2:

Para las personas que reciben hemodiálisis crónica, recomendamos administrar terapia con hierro intravenoso. La terapia con hierro por vía oral en estas personas puede aplicarse sólo si:

• La terapia con hierro intravenoso está contraindicada o
• La persona decide no recibir tratamiento con hierro intravenoso, después de discutir la eficacia relativa y los efectos secundarios de la terapia con hierro oral e intravenoso.

(Recomendación fuerte a favor)

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Recomendación 1:
En pacientes con ERC y anemia, sugerimos iniciar la administración de AEE si el nivel de hemoglobina (Hb) es menor a 11 g/dL. (Recomendación débil a favor)

BPC 1:
Si existe deficiencia absoluta de hierro, considerar manejar esta deficiencia de hierro antes del inicio de AEE.

BPC 2:
Evaluar de forma individualizada los beneficios y riesgos del uso de AEE, tomando en cuenta las comorbilidades y el pronóstico del paciente. Algunos factores que deberían tenerse en cuenta son: el rango de caída de la concentración de hemoglobina, la respuesta a tratamiento con hierro, el riesgo de necesitar transfusión y los riesgos relacionados a los tratamientos con AEE.

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Recomendación 1:
Para personas con ERC y anemia recomendamos utilizar la eritropoyetina disponible (epoetina alfa) para el tratamiento de la anemia, evaluando previamente el estado del paciente y la ruta de administración. (Recomendación fuerte a favor)

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Recomendación 1:
En pacientes con ERC que requieran la administración de epoetina alfa, sugerimos usar la vía subcutánea o intravenosa. (Recomendación débil a favor, certeza baja de la evidencia)

BPC 1:
Considerar administrar epoetina alfa por vía intravenosa en pacientes en hemodiálisis, y administrala por vía subcutánea en pacientes que no están en hemodiálisis.

BPC 2:
Cuando se use la vía intravenosa, considerar un ajuste de dosis mayor.

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Recomendación 1:
En personas con ERC y anemia, en tratamiento con epoetina alfa, recomendamos mantener una dosis promedio de epoetina menor a 10000 unidades/semana. (Recomendación fuerte a favor)

Recomendación 2:
En personas con ERC en prediálisis y anemia, sugerimos administrar la epoetina alfa con una frecuencia de dosis de una vez por semana o una vez cada dos semanas, valorando la severidad de la anemia del paciente. (Recomendación débil a favor)

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Recomendación 1:
En personas con ERC y anemia, recomendamos mantener una Hb objetivo entre 10.0 y 12.0 g/dL. (Recomendación fuerte a favor)

BPC 1:
Para mantener el nivel de Hb dentro del rango objetivo, no espere hasta que los niveles de Hb estén por debajo del objetivo terapéutico, para ajustar el tratamiento. Se debe ajustar el tratamiento cuando los niveles de Hb alcancen un valor 0.5 g/dL mayor al objetivo terapéutico.

BPC 2:
Evalúe aceptar niveles de Hb debajo de los objetivos terapéuticos si se requiere altas dosis de epoetina alfa para alcanzar los niveles objetivo, o si no alcanza niveles objetivo, a pesar de administrar una dosis mayor.

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BPC 1:

En personas con ERC y anemia en tratamiento con AEE, sospechar de resistencia a los AEE si:

• Se han investigado otras causas de anemia (desnutrición, hiperparatiroidismo, inflamación crónica, infección, pérdida sanguínea, neoplasia, diálisis inadecuada, toxicidad por aluminio), y
• No se alcanza el nivel objetivo de Hb a pesar del tratamiento con 300 UI/Kg/semana o más de epoetina subcutánea, o 450 UI/Kg/semana o más de epoetina endovenosa; o existe una necesidad continua de administrar AEE

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BPC 1:
Evaluar y discutir los riesgos y beneficios de la transfusión de glóbulos rojos con el paciente (o, cuando corresponda, con sus familiares o cuidadores).

BPC 2:
Considerar la indicación de transfusión sanguínea cuando:

• Se requiere una rápida corrección de la anemia para estabilizar la condición del paciente (por ejemplo, en casos de hemorragia aguda o isquemia miocárdica inestable) o es necesario corregir rápidamente la Hb para una cirugía.
• Persisten los síntomas y signos de anemia, con respuesta ineficaz a la terapia con AEE.

Los riesgos de administrar AEE superan los riesgos de transfusión de sangre.

BPC 3:
Evitar, en lo posible, corregir la anemia con transfusiones de sangre en personas con ERC candidatos a trasplante renal.

BPC 4:
De decidir realizar transfusiones de sangre en personas con ERC candidatos a trasplante renal, utilizar el filtro leucorreductor.

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