Anemia in CKD: Diagnosis

In our previous article, we talked at length about what Anemia exactly is, and the reasons for why it inevitably appears in all patients with Chronic Kidney Disease. The next article under “The Anemia Series” elucidates on the specific Clinical Protocol that we Doctors are taught to follow to be able to diagnose Anemia in CKD.

Your Doctor will need to complete a three-step analysis before making a conclusive point on whether you have Anemia or not. These are:



In good health, Red Blood Cells (RBCs) in our body help transport Oxygen to different tissues of our body. This provides tissues with the necessary fuel & helps them to carry out day-to-day activities. RBCs do so, with the help of a special protein namely “Hemoglobin” found within each of them.

Any disruption in this arrangement would deprive tissues of adequate oxygen, make them go malnourished and produce various symptoms that we associate with Anemia. Such Symptoms include but are not limited to:


1. Weakness

2. Fatigue, or feeling tired

3. Palpitation (short episodes of rapid heartbeat that you may feel for yourselves)

4. Difficulty breathing or shortness of breath with mild exercise

5. Chest Pain

6. Headaches

7. Problems with concentration

8. Paleness

9. Dizziness

10. Cold hands & feet (not always)

11. Hairfall (in some cases)

12. Difficulty sleeping at night

13. Pica (the urge to eat or chew on non-food substances such as Chalk, Mud or Metal)

It is these “symptoms” that your Doctor will ask you about in the first instance. This constitutes Medical History-taking and is the first step towards diagnosing Anemia in the clinic.



After carefully considering your symptoms, your doctor will check you specifically for the following clinical signs indicative of Anemia. Physical Examination constitutes the second step in the clinical diagnosis of Anemia. Doctors check the following parameters:



Doctors will check your lower eyelids, your tongue, nailbeds in hands & feet and the creases in the palm of your hands to look for “a pale appearance” or “pallor” as compared to what’s usually seen in good health. These sites are normally rich in blood supply that gives them a pinkish tinge in healthy individuals. As soon as Anemia hits, our bodies automatically “tend to reduce” blood circulation to these areas in order to “conserve” blood for major internal organs such as the Heart, Lungs, Brain Kidneys & Liver. Hence, these sites are the earliest to “go pale” in an anemic person. This is why Doctors are taught to check these specific sites to look for Pallor while trying to diagnose Anemia.

Refer to the picture below to see the difference for yourself!



Your doctor may check the temperature of your limbs as part of your Physical Examination. Many anemic patients can have cold hands & feet. Let us explain why.

Low RBC numbers or low Hemoglobin content in Anemia compromises our in-house Oxygen transport & delivery system. This warrants for our body to prioritize major internal organs such as the Heart, Brain, Kidney, Liver & Lungs over relatively less important ones such as our hands & feet. As a result, in anemic persons with “less blood”, our body ends up “reducing” the blood supply to their hands and feet to “conserve” blood for internal organs. Since blood circulation normally keeps our body warm, a curb on it can turn our limbs cold.



Your doctor will check your chest with a stethoscope to assess your heart beat and will note down your pulse rate from the wrist.

Anemia HR

Anemic patients who have not started treatment yet may have a high Heart rate & Pulse rate. Wondering why? Read on!

Once tissues start suffering from low Oxygen supply due to a drop in RBC numbers in Anemia in CKD, our Heart kindly offers to help by starting to “pump blood faster than normal”. This translates as a raised Heart Rate and Pulse Rate (beyond 100 beats per minute as opposed to a normal range of 60-100 beats per minute). This is also the reason for anemic patients reporting occasional palpitations (sudden, short episodes of feeling a rapid heartbeat).

In addition, doctors often measure your blood pressure during this Physical Examination.

Once over with examining you, Doctors finally move on to ordering Laboratory Tests for you, to confirm their clinical “suspicions” of your being Anemic.




After jotting down your symptoms and checking you for Anemia-specific clinical signs, the next logical step is to confirm the clinical judgment via your blood work. But before we go into detail, here’s some food-for-thought.

Technically, anemia is defined as an abnormal fall in Red Blood Cell (RBC) count. But if you think about it, it’s not just about RBC numbers.

Conditions such as:

■ A low hemoglobin content despite a “normal” RBC count


■ Smaller than normal RBCs that fit less hemoglobin per RBC

would also compromise Oxygen supply to tissues & deprive them of the necessary “fuel” to produce symptoms of Anemia in a similar way as a low RBC count.


Hence, to confirm Anemia, your doctor will order blood tests that check for Red Blood Cell (RBC) numbers, RBC dimensions & overall Hemoglobin content.


A “Complete Blood Count (CBC)” also called “Complete Hemogram” is sufficient to address all the above aspects.

Now we at ATK want you to be self-sufficient when it comes to understanding the Reports of your Blood Work. This is so you are prepared to ask the right questions to your medical team during your (frustratingly!) “timed” medical appointments.

Keeping in sync with our motive, we want you to become capable of analyzing your Complete Hemogram or CBC test reports and find if you are anemic or not.

However, once you sit down to do so, you will need to be equipped with TWO facts:

* Anemia CKDThe knowledge of which specific abbreviations to check for Anemia

* Anemia CKDWhat those abbreviations stand for.


This is why we have put together a comprehensive table explaining the above questions with just the right amount of detail, especially for you.


HbHemoglobin ContentAdult males :
13-18 g/dL
Adult Females:
12-15 g/dL
As per latest KDIGO norms:

Adult males:
Less than 13 g/dL

Adult Females:
Less than 12 g/dL

"Total Count of Red Blood Cells (RBC) also called Erythrocytes (erith-ro-sites)
Adult males:
5-5.5 million RBCs/cc

Adult Females:
4.5-5 million RBCs/cc
Adult males:
Less than 5 million RBCs/cc

Adult Females:
Less than 4.5 RBCs/cc
HEMATOCRIT / PCVPCV stands for "Packed Cell Volume".

It refers to the proportion of Red blood cells among all other components of blood as a whole. It is also called "Hematocrit".
Adult males: 38.3-48.6%

Adult Females: 35.5-44.9%
Adult Males: Less than 38%

Adult Females: Less than 35%
MCVStands for "Mean Corpuscular Volume".

Indicates the average volume (holding capacity) of each Red Blood Cell (RBC)
80-96 fL/RBC

(fL = Femtolitre;
1 femtolitre is 1 trillionth of 1 millilitre)
Less than 80 fL

Values less than 80 femtolitre indicate smaller than normal RBCs. These are unable to hold adequate hemoglobin content. Hence produce symptoms of Anemia.
MCHStands for "Mean Corpuscular Hemoglobin".

Indicates the average Hemoglobin content present in each red blood cell (RBC) of the sample tested.
27-33 pg

(pg= picogram;
1 picogram is 1 trillionth of 1 gram weight)
Less than 27 pg

Values below 27 picograms compromise our in-house Oxygen transport systems & produce symptoms of Anemia.
MCHCStands for "Mean Corpuscular Hemoglobin Concentration".

It is the overall Hemoglobin content in your blood as a whole.
33-36 g/dLMCHC less than 33 g/dL qualifies as Anemia.
RDWStands for "Red Cell Distribution Width".

Indicates the average distance between adjacent RBCs.

It helps understand variations seen in the size and holding capacity of red blood cells (RBCs).

Depending on the machine that your laboratory uses, RDW could be reported in two ways:

1. RDW-SD i.e. Red Cell Distribution Width - Standard Deviation. This is purely a measure of RBC size independent of RBC holding capacity.


2. RDW-CV that is, Red Cell Distribution Width - Co-efficient of Variation. This parameter measure RBC size "in relation to" RBC holding capacity.

39-46 fL

More than 46 fL

More than 15%

Since Anemia causes a drop in RBC numbers, it would show as less number of RBCs that are "more spaced-out" than normal.

This means, the average distance between RBCs would increase in Anemia.

Hence unlike other parameters here, RDW "increases" in Anemia.

Once your doctor analyzes your blood test reports, he/she is in a position to provide you with a confirmed diagnosis and gets to decide whether you need to be treated for Anemia or not.



The tests mentioned above help your doctor to find out if you are Anemic or not. If you have already been diagnosed with Anemia and are on medication for the same, your doctor will want to monitor how well you are responding to the treatment. For that, your doctor will order some additional blood tests apart from CBC. More on this in our next article that would explain to you, the various treatment options available to treat Anemia in Chronic Kidney Disease and their possible implications on your kidney disease process. Till then, stay informed. Stay tuned!



1. Mayo Clinic — Hematocrit 
2. MedScape — Red Cell Indices
3. MedScape — RDW



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