KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease



Red blood cell transfusions should be used judiciously in patients with CKD, especially because of the potential development of sensitivity, affecting future kidney transplantation. However, despite the use of ESA and iron therapy, transfusion with red blood cells occasionally is required, in particular in the setting of acute bleeding.

3.4.1 (FULLY APPLICABLE TO CHILDREN) In the opinion of the Work Group, no single Hb concentration justifies or requires transfusion. In particular, the target Hb recommended for chronic anemia management (see Guideline 2.1) should not serve as a transfusion trigger.


There is no good evidence to support any different recommendations in children compared with adults with respect to this guideline because the physiological principles underlying this guideline hold true in children with anemia and CKD.The pediatric practitioner also may wish to consider the following evidence.

Currently, there are no specific guidelines related to transfusion of red blood cells in children with any level of CKD, on or off dialysis therapy. However, it should be recognized that any of these children, as with an adult, will benefit most from red blood cell transfusions only in the face of impaired oxygen delivery, ie, not based on an Hb “number.” Poor oxygenation is a universally followed indication for transfusions in children older than the neonate who do not have concurrent hematologic symptoms or CVD.271,373,374

It also should be remembered that red blood cell transfusions, at least in the critically ill pediatric patient, may not be “benign” therapy. This was highlighted by a retrospective cohort study of 240 children in 5 pediatric intensive care units, 130 of whom received red blood cell transfusions. The study showed that even after controlling for a number of factors, such transfusions were associated with increased use of oxygen, days of mechanical ventilation, vasoactive agent infusions, length of intensive care unit stay, and total length of hospital stay (all P < 0.05).373

Finally, with respect to transfusions in pediatric patients awaiting renal transplantation, it is possible that the need for or use of packed red blood cell transfusions may benefit the pediatric patient if chosen carefully and provided under immunosuppressive coverage in a planned manner. The most current and largest study involved 193 children, 91 of whom received 2 sequential blood transfusions, either random or donor specific if a living related donation was expected, done 1 month apart under cover of oral cyclosporine.375 Significant improvements in both 1-year and 5-year graft survival were reported: 96% versus 78% and 90% versus 64% (P < 0.001). Whereas not minimizing the risk for transmission of infectious agents from blood transfusions, especially if that transfusion is unnecessary, data suggest further prospective trials of red blood cell transfusion before transplantation might be of value in children.