In the United States, patients with renal transplants account for about 16% of all people who have a glomerular filtration rate of less than 30 ml/min (stage 4 chronic kidney disease) or who require renal replacement treatment.1 2 About 40% of patients with a kidney transplant have anaemia, and half of these are treated with erythropoietins.3 Management of anaemia in patients with a kidney transplant is complicated by their long history of renal disease, the inflammation associated with infection or rejection, and immunosuppressive medication.4

Compared with patients who have chronic kidney disease, kidney transplant recipients tend to be younger, more active, and less likely to have cardiovascular disease, although they may develop anaemia at a relatively higher glomerular filtration rate.3 Despite these differences, the linked study by Heinze and colleagues (doi:10.1136/bmj.b4018) indicates that the association between anaemia and mortality previously observed in other patients with low glomerular filtration rate is also present in kidney transplant recipients.5 Unfortunately, this study raises concerns …