Optimal management of anemia in patients with chronic kidney disease to keep hemoglobin levels within acceptable ranges involves nutritional, inflammatory, mechanical, and immunological factors that are unique for each patient, as are patient responses to erythropoiesis-stimulating agents.

In a case report, Karen Courville, MD, and colleagues described a 68-year-old male patient with a history of type 2 diabetes mellitus (20 years) who was treated with low dose intermediate insulin, hypertension controlled with calcium channel blocker and angiotensin-converting enzyme (ACE) inhibitors, pulmonary emphysema secondary to smoking, and stage 5 chronic kidney disease (CKD) [Clinical Case Reports. doi:10.1002/ccr3.6027].

The patient presented with severe anemia with acute worsening secondary to angioectasias, vascular malformations that are seen more frequently in patients with CKD requiring hemodialysis than in patients with normal kidney function. Angioectasias in patients with CKD on hemodialysis may present with chronic anemia that is resistant to erythropoietin or with recurring digestive bleeding requiring frequent transfusions.

“This case is of interest because it should remind us that anemia in patients receiving hemodialysis may become a diagnostic challenge, as it is multifactorial and will require participation of diverse clinical specialties and a well-orchestrated treatment,” the authors said.