Recommendation of ESA

1. For patients with CKD not on dialysis

Consider initiating ESA treatment only when the Hb level is <10 g/dL and the following considerations apply:

1. The rate of Hb decline indicates the likelihood of requiring a red blood cell (RBC) transfusion.
2. Reducing the risk of allo-immunization and/or other RBC transfusion-related risks is a goal.
3. If the Hb level exceeds 10 g/dL, reduce or interrupt the dose of ESA and use the lowest dose of ESA sufficient to reduce the need for RBC transfusions. If the Hb level approaches or exceeds 11 g/dL, reduce or interrupt the dose of ESA.
4. When initiating or adjusting therapy, monitor Hb levels at least weekly until stable, then monitor at least monthly.
5. For patients who do not respond adequately over a 12-week escalation period, increasing the ESA dose further is unlikely to improve response and may increase risks.