Anemia, commonly seen in patients with chronic kidney disease (CKD), is due to a relatively reduced production of erythropoietin by renal interstitial fibroblasts. The development of cancer in patients with kidney disease puts them at a higher risk of developing severe anemia along with its antecedent problems. The treatment of anemia in patients with cancer has changed substantially in recent years. This is partly due to results from a large number of published studies that indicate an increased risk of mortality and tumor progression with erythropoiesis-stimulating agents (ESA) therapy, which may have been overstated, on careful review of the literature. In the nephrology literature, studies exploring the normalization of hemoglobin with erythropoietin treatment have found increased cardiovascular and thromboembolic events, and risk of death. Many CKD and dialysis patients receive ESA to maintain a hemoglobin goal in the range of 9-11.5 g/dL. In patients with kidney disease, a cancer diagnosis makes the treatment of anemia challenging. In this review, we discuss the pathobiology of anemia in kidney disease, the benefits and risks of ESA treatment in CKD patients with cancer, and provide recommendations on ESA treatment for clinicians taking care of this unique subset of patients.
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