Anemia in patients hospitalized with COVID-19 can be severe, but in most cases, clinicians should limit their use of erythropoiesis-stimulating agents (ESAs), according to a recent editorial.

In this inflammatory environment, treatment with ESAs would not only have limited effectiveness but could also be potentially harmful, according to Steven Fishbane, MD, and Jamie S. Hirsch, MD, of North Shore University Hospital in Great Neck, New York, writing in the American Journal of Kidney Diseases. They explained that COVID-19 and ESAs can both promote thrombosis.

Among 11,265 patients with COVID-19 admitted to 13 Northwell Health hospitals in New York from March 1 to April 27, 2020, clinicians observed elevated concentrations of D-dimer, lower hemoglobin values, and greater serum ferritin concentrations, possibly reflecting elevated hepcidin, according to the editorial.

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Based on their recent experience, Dr Fishbane and Dr Hirsch recommended that nephrologists treating patients with COVID-19 avoid using ESAs in anemic patients with or without AKI. The risks of ESA treatment generally outweigh potential benefits. Very low hemoglobin may require blood transfusion. For patients on maintenance dialysis admitted to the hospital with COVID-19 and anemia, nephrologists should lower hemoglobin targets 8 to 9 g/dL to mitigate thrombotic risk. Nephrologists should not escalate ESA doses if the goal cannot be achieved.

Disclosure: One of the authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Fishbane S, Hirsch JS. Erythropoiesis-stimulating agent treatment in patients with COVID-19 [published online May 29, 2020]. Am J Kidney Dis. doi: 10.1053/j.ajkd.2020.05.002