The results of previous large clinical trials have revealed that low hemoglobin (Hb) levels are significantly associated with adverse events (cardiovascular disease, infection, hospitalization, and mortality) in patients with chronic kidney disease (CKD). However, in the general population, the mean Hb levels differ by sex and age. Furthermore, the comorbidities and activities of daily living of elderly patients are markedly different from those of nonelderly patients. CKD in elderly patients is accompanied by not only chronic inflammation, which is more severe than that in nonelderly patients, but also changes in the secretion of sex hormones with aging and decreases in erythropoiesis in the bone marrow. Thus, it is presumed that compared with nonelderly CKD patients, elderly CKD patients are hyporesponsive to erythropoiesis-stimulating agents (ESAs) and show the dysutilization of iron for erythropoiesis. However, in these patients, the target Hb levels and the appropriate doses of ESA and iron preparations are not indicated clearly. Recent clinical trials have reported that higher Hb levels, the same as those in nonelderly CKD patients, might not necessarily improve the quality of life or survival of elderly CKD patients. We have also revealed that hyporesponsiveness to ESAs and higher doses of intravenous iron affect the adverse events occurring in elderly patients undergoing maintenance hemodialysis compared with nonelderly CKD patients. Therefore, before the administration of ESAs and iron preparations to elderly CKD patients, the pathophysiological characteristics of these patients should be considered.
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