reviews

Erythropoietic stress and anemia

in diabetes mellitus
Dhruv K. Singh, Peter Winocour and Ken Farrington
Abstract | Anemia is one of the world’s most common preventable conditions, yet it is often overlooked,
especially in people with diabetes mellitus. Diabetes-related chronic hyperglycemia can lead to a hypoxic
environment in the renal interstitium, which results in impaired production of erythropoietin by the peritubular
fibroblasts and subsequent anemia. Anemia in patients with diabetes mellitus might contribute to the
pathogenesis and progression of cardiovascular disease and aggravate diabetic nephropathy and retinopathy.
Anemia occurs earlier in patients with diabetic renal disease than in nondiabetic individuals with chronic
kidney disease. Although erythropoietin has been used to treat renal anemia for nearly two decades, debate
persists over the optimal target hemoglobin level. Most guidelines recommend that hemoglobin levels be
maintained between 105 g/l and 125 g/l. The suggested role of anemia correction—to prevent the progression
of left ventricular hypertrophy in patients with diabetes mellitus—is yet to be established. However, an
emphasis on regular screening for anemia, alongside that for other diabetes-related complications, might help
to delay the progression of vascular complications in these patients.
singh, D. K. et al. Nat. Rev. Endocrinol. 5, 204–210 (2009); doi:10.1038/nrendo.2009.17

Introduction
The prevalence of diabetes mellitus is increasing world-
wide; this condition is likely to affect approximately
300 million people by 2025.1 Improved medical care
and scientific advances in the treatment of patients have
helped to prolong their lifespan. However, increased sur-
vival potentially predisposes such patients to long-term
complications and consequent reductions in quality
of life.2
one of these long-term complications is anemia, a
condition characterized by reduced hemoglobin levels
(<130 g/l in males and <120 g/l in females3). In a cross-
sectional study by Thomas et al.,4 approximately one
quarter of patients who attended a diabetes clinic were
anemic. Anemia is an independent risk factor for the
development and progression of cardiovascular disease,5
congestive heart failure,6 and chronic kidney disease,7 and
a potential contributing factor to the development
and progression of diabetic retinopathy 8 and other dia-
betic complications.9,10 Patients with diabetes mellitus
might be especially vulnerable to the adverse effects of
anemia in the presence of cardiovascular disease and
Lister Hospital, hypoxia-induced organ damage.4 Chronic anemia can
stevenage, UK adversely affect psychological and physical develop-
(DK Singh,
K Farrington). Queen
ment, cognitive function, appetite and exercise toler-
elizabeth ii Hospital, ance,11 and might cause fatigability, malaise, dyspnea
welwyn Garden City, UK
and heart palpitations (Box 1). Anemia is a modifiable
(P Winocour).
risk factor; its correction substantially improves quality
Correspondence: of life for patients with chronic kidney disease12 and
DK singh, Lister
Hospital, Coreys Mill
might help to arrest its progression. 13 Nevertheless,
Lane, stevenage,
Hertfordshire sG1 4AB,
Competing interests
UK
dsingh4@nhs.net The authors declared no competing interests.
correction of anemia in these patients is far from opti-
mized; this situation might be caused by various factors,
including the uncertainty that surrounds the optimum
target levels of hemoglobin, the costs of erythropoiesis-
stimulating agents, erythropoietin resistance secondary
to concurrent hematinic deficiency, chronic inflam-
mation or hyperparathyroidism. In this Review, we sum-
marize the diabetes-related events that might lead to the
development of anemia, and discuss potential clinical
approaches to treatment of this condition.
Causes of anemia in diabetes mellitus
The etiology and pathogenesis of anemia in diabetes
mellitus is multifactorial (Figure 1). Chronic hyper-
glycemia might result in abnormal red blood cells, oxi-
dative stress, and sympathetic denervation of the kidney
related to autonomic neuropathy. These factors promote
a hypoxic environment in the renal interstitium, which
leads to impaired production of erythropoietin by the
peritubular fibroblasts. Inappropriately low erythro-
poietin level is an important cause of early anemia in
patients with diabetes mellitus14 (the multiple functions
of erythropoietin are summarized in Box 2). Before
any functional deficiency of erythropoietin is evident,
however, several other factors might contribute to the
development of a chronic hypoxic milieu, which pro-
motes erythropoietic stress and potentiates the develop-
ment of early anemia. These factors include diabetic
nephropathy, chronic inflammation, elevated levels
of advanced glycation end products, iron deficiency,
antidiabetic medications, diabetic neuropathy, and low
testosterone levels.15

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Diabetic nephropathy
Diabetic nephropathy is a long-term, microvascular
complication of diabetes mellitus that is charac terized
by progressive angiopathy of capillaries within the renal
glomeruli. with increased life expectancy of patients with
diabetes mellitus, diabetic nephropathy has become the
most common cause of end-stage renal disease and renal
anemia in developed countries. 16 Anemia also occurs
in patients with nondiabetic, chronic kidney disease,17
but a decrease in erythropoietin level and symptoms of
anemia in these patients develop later and are usually less
severe than in those with diabetic nephropathy who have
similar degrees of renal impairment.4,14,18
Dysfunction of renal tubules
microalbuminuria is the first detectable clinical sign of
an increased risk of diabetic nephropathy.4,7 However,
early dysfunction in renal tubules, which are the primary
sites of erythropoietin production, has been reported
in patients with diabetes mellitus before the onset of
microalbuminuria.19 urinary excretion of tubular injury
markers, such as N-acetyl-β-glucosaminidase, a tubular
enzyme, and retinol-binding protein have been reported
to increase in both type 120 and type 219 diabetes mel-
litus. These findings imply that renal tubular dysfunc-
tion is disturbed in diabetes mellitus well before the onset
of microalbuminuria.
Tubular ischemia
Glucose uptake by renal tubules occurs independently of
insulin action. Direct exposure to high concentrations
of glucose as a result of chronic hyperglycemia might
lead to abnormal cell growth and collagen synthesis21 and
early apoptosis of tubular cells.22 In addition, this condi-
tion is associated with increased production of advanced
glycation end products and polyols, and increased secre-
tion of protein kinase C and angiotensin II in the renal
tubules. These changes can result in vasoconstriction
and tubular ischemia.23
Peritubular capillaries are vital for the survival and
normal function of tubular cells. Chronic hyperglycemia
coupled with renal vasoconstriction and the above-
mentioned cellular changes might adversely affect the
sur vival of cells in the peritubular capillaries when
the con centration of nitric oxide is in adequate. 24
Inadequate avail ability of nitric oxide could lead to
increased vascular tone and enhanced uptake of oxygen;25
therefore, chronic hyperglycemia can compromise the
microcirculation in the renal interstitium. 26 This con-
dition also results in increased lactate concentration in
the renal medulla, which reduces pH levels and further
hampers oxygen availability in the renal interstitium.27
Tubular and interstitial cells in the juxtamedullary
region and outer medulla are, even under normal condi-
tions, in a state of relative hypoxia. This hypoxia is a result
of the countercurrent exchange of oxygen within the vasa
recta and high consumption of oxygen by cells in the
medullary thick ascending limb and the s3 segments of
NATuRe RevIews | EnDoCrinology
© 2009 Macmillan Publishers Limited. All rights reserved
reviews
Key points
■ Anemia is a common complication of diabetes mellitus and an independent
contributor to the pathogenesis and progression of other diabetes-related
complications
■ erythropoietic stress in diabetes mellitus might be caused by elevated levels
of advanced glycation end products, oxidative stress, endothelial dysfunction,
abnormal red blood cells and reduced bioavailability of nitric oxide
■ Anemia occurs earlier in patients with diabetic nephropathy than in nondiabetic
individuals with comparable renal function
■ in patients with diabetes mellitus, correction of anemia improves quality of life
and might delay the progression of diabetic complications; therefore, routine
screening for anemia is recommended in this population
■ Until definitive evidence of optimal hemoglobin levels is available, treatment
should aim to achieve levels of 105 g/l–125 g/l
Box 1 | simplified classification of common anemias
normochromic, normocytic anemia (normal MCV 80–100 fl)
■ Anemia due to chronic disease
■ renal anemia (erythropoietin-deficiency anemia)
■ Hemolytic anemia
■ Hemoglobinopathies
■ Anemia due to acute blood loss
■ Aplastic anemia
■ Anemia secondary to malignancy or drugs
Hypochromic, microcytic anemia (MCV <80 fl)
■ iron-deficiency anemia
■ Thalassemias
normochromic, macrocytic anemia (MCV >100 fl)
■ vitamin B12 deficiency
■ Folate deficiency
Abbreviation: MCv, mean corpuscular volume.
the proximal tubules.28 The hypoxic milieu stimulates the
production of hypoxia-inducible factor 1 (HIF-1), which
is one of the major mediators in the adaptation of cells
to hypoxia. HIF-1 promotes vasculogenesis, improves
oxygen availability and modulates cellular metabolism.29
HIF-1 might also protect against fibrotic processes
within the kidney by influencing genes that promote
fibrosis. In addition, HIF-1 influences pathways that are
involved in glucose metabolism,30 cellular growth and
apoptosis,31 production of erythropoietin and vascu-
lar endothelial growth-factor, and metabolism of iron
and the extracellular matrix.32 Hyperglycemia impairs
the mechanisms that protect HIF-1 from protease
degradation in a dose-dependent fashion,33 and the
resultant reduced HIF-1 action on profibrotic genes
might promote interstitial fibrosis.29 This process might
exacerbate local ischemia by inhibiting oxygen diffusion
from the capillary to the tubule. All these alterations
generate a hypoxic milieu in the tubular interstitium;
this hypoxia could hamper the functional ability of
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 reviews
Chronic inflammation Chronic kidney disease
Advanced glycation
�
Diabetic neuropathy
�
end products
? Testosterone deficiency Stabilization of HIF 1
�
Anemia
in diabetes
Hematinic malabsorption ? EPO resistance
mellitus
Renal oxygen concentration
�
EPO production
�
Abnormal red blood cells ? Impaired erythropoiesis
Adverse effects of ACE
? Functional deficiency of EPO
inhibitors or ARBs
Figure 1 | Factors that contribute to anemia in diabetes mellitus. Abbreviations:
ACe, angiotensin-converting enzyme; ArBs, angiotensin ii receptor blockers; ePO,
erythropoietin; HiF-1, hypoxia inducible factor 1.
Box 2 | Physiological effects of erythropoietin
erythropoietin is a glycoprotein hormone that is
produced by the peritubular fibroblasts in the kidneys
and stimulates erythropoiesis in response to hypoxia.81
it has multiple effects,82 and its actions extend well
beyond erythropoiesis.83 The extrahemopoietic functions
of erythropoietin include cytoprotection,84 inhibition of
apoptotic death,84 antioxidant properties,85 and anti-
inflammatory effects.86 erythropoietin manifests its
trophic properties by stimulation of the erythropoietin
receptors on the tissue surface.87 These receptors
have been located on glomerular podocytes88 and renal
tubular cells.89
peritubular fibroblasts, which are primarily responsible
for the production of erythropoietin.
Erythropoietin deficiency
As mentioned above, anemia as a result of erythropoietin
deficiency occurs earlier in patients with type 1 or type 2
diabetes mellitus who have chronic kidney disease than
in nondiabetic individuals with chronic kidney disease.
A defect in ‘anemia-sensing’ or a resistance to erythro-
poietin action are both suggested as probable mecha-
nisms of early-onset anemia in type 1 diabetes mellitus
and might be related to splanchnic denervation as a result
of diabetic autonomic neuropathy.34 Inadequate erythro-
poietin responses in diabetes mellitus can be caused
by low levels of erythropoietin,35 functional erythro-
poietin deficiency 36 and/or erythropoietin resistance.37
modulation of erythropoietin receptors as a result of
glycation may also render erythropoietin ineffective.38
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Inadequate erythropoietin action might promote low
hemoglobin levels that can lead to hypoxia, which in turn
might stimulate erythropoietin to be produced by the sur-
viving peritubular cells. In the long run, the extra work
this process places on the surviving cells might prove to be
counterproductive for the remaining cells, and exacerbate
apoptosis in the persistent hypoxic environment. unabated
tubular apoptosis as a result of chronic hyperglycemia
and interstitial fibrosis would also cause a reduction in
the number of functional erythropoietin receptors. These
processes can have a cumulative effect in the precipitation
of early anemia in diabetes mellitus.
Chronic inflammation
Diabetes mellitus is a chronic inflammatory state that
is characterized by increased levels of proinflammatory
cytokines, which are detectable before the development of
renal impairment.39 studies of proinflammatory cytokines,
such as interleukin-1, tumor-necrosis factor (TNF) and
interferon-γ, suggest that they have an important role in
the development of anemia in chronic diseases. This role
involves suppression and apoptosis of erythroid progenitor
cells.40,41 Hyperactivity of the cytokine network might
modulate other aspects of anemia in chronic diseases, such
as impairment of iron release, and contribute to chronic
inflammation, which results in poor response to treatment
with recombinant human erythropoietin in patients with
erythropoietin-deficiency anemia.
Advanced glycation end products
Advanced glycation end products are a diverse group
of end-product molecules that are formed as a result of
nonenzymatic, covalent binding of glucose residues to the
free amino groups of proteins, lipids, and nucleic acids.
Increased production of advanced glycation end pro-
ducts has been implicated in the development of micro-
angiopathy in diabetes mellitus.42 Increased accumulation
of these products can promote nonenzymatic glycation of
red-blood-cell-membrane glycoproteins and hemoglobin,
which leads to impaired deformability of red blood cells
in diabetes mellitus.43 These molecules might also increase
the level of oxidative stress in diabetes mellitus by stimu-
lating increased production of free oxygen radicals.44
Advanced glycation end products have a major role in the
pathogenesis and progression of diabetic nephropathy 45
and diabetic neuropathy.46
oxidative stress
Increased production of oxidative stress boosters, such
as oxygen free radicals and other reactive oxygen species,
might also have a role in the development of diabetic
nephropathy.47 Reactive oxygen species combine with
nitric oxide in the endothelium to form reactive oxygen
inter mediates, such as peroxynitrite, which reduce
the total bioavailability of nitric oxide.48 As mentioned
before, this change might lead to an increase in vascular
tone and increased oxygen expenditure.25 A reduction
in the renal oxygen concentration, along with impaired
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bioavailability of nitric oxide, might increase damage
caused by free radicals in the tubular interstitium. As
mentioned above, these alterations generate a hypoxic
milieu in the tubular interstitium, which has inhibits the
production of erythropoietin.
Abnormal hematinic absorption
Hematinics, such as folic acid, vitamin B12 and iron, are
micronutrients that are vital to stimulate the formation of
red blood cells or to increase hemoglobin levels in anemic
individuals. Diabetes-related metabolic derangements
might also contribute to anemia. Patients with diabetes
mellitus have an increased prevalence of chronic gastritis49
and Helicobacter pylori infection,50 and these conditions
influence the absorption of nutrients, including dietary
iron, from the stomach. some patients with type 1 diabetes
mellitus harbor antibodies against parietal cells, which
increase their risk of developing iron-deficiency anemia
and atrophic gastritis.51 some patients also have an associ-
ated malabsorptive disorder, such as celiac disease, that
hampers iron absorption and overall nutrient intake.52
Adequate iron stores are essential to support normo-
blast proliferation and maturation during erythropoiesis.
Inadequate iron stores can result in decreased responsive-
ness of erythropoiesis to erythropoietin. 53 In clinical
practice, iron deficiency is the most common cause of
resistance to exogenous erythropoietin. 54 The preva-
lence of iron deficiency has been reported to be higher in
patients with diabetes mellitus than in nondiabetic indivi-
duals.55 This difference might be explained by the fact
that chronic hyperglycemia promotes the modulation of
transferrin receptors by glycation, which might impair the
capacity of these receptors to bind iron, and thus reduce
iron availability.56
Medications
Patients with type 2 diabetes mellitus often take multiple
medications for the control of diabetic symptoms and
other concomitant conditions. metformin, one of the
most commonly used oral antidiabetic agents, has been
associated with malabsorption that leads to vitamin B12
deficiency,57 which can potentially result in megaloblastic
anemia in susceptible individuals. B12 deficiency impairs
purine and thymidylate syntheses, hampers DNA synthe-
sis, and promotes erythroblast apoptosis, which results
in anemia due to ineffective erythropoiesis. Glitazones
can precipitate anemia, probably as a result of hemo-
dilution secondary to fluid retention.58 Antihypertensive
medications, such as angiotensin-converting-enzyme
inhibitors59 and angiotensin II receptor blockers,60 might
adversely influence erythropoiesis and promote anemia by
inhibition of the growth of erythroid precursors.
Abnormalities of red blood cells
The lifespan of red blood cells might be decreased in
patients with diabetes mellitus.61 Red blood cells are affected
by various disturbances in the hematopoietic milieu, such as
chronic hyperglycemia and hyperosmolarity,62 overactivity
NATuRe RevIews | EnDoCrinology
© 2009 Macmillan Publishers Limited. All rights reserved
reviews
Advanced glycation
�
Oxygen affinity in RBCs
�
end products
Reactive oxygen species Activity of Na+,K+–ATPase
�
Free radical damage Sorbitol levels in RBCs
�
Diabetes
mellitus
Oxidative stress Lifespan of RBCs
�
Endothelial dysfunction Osmotic fragility of RBCs
�
Bioavailability of nitric oxide Membrane viscosity of RBCs
�
Figure 2 | Changes in diabetes mellitus that lead to erythropoietic stress.
Abbreviation: rBCs, red blood cells.
of the polyol pathway 63 and increased levels of advanced
glycation end products.64 These disturbances lead to ele-
vated internal viscosity and increased membrane rigidity in
these blood cells.65 In experimental models of diabetes mel-
litus, several other metabolic and functional abnormalities
have been described in red blood cells, including elevated
sorbitol levels,63 diminished Na+, K+-ATPase activity 66
and markedly increased activity of acetylcholinesterase.67
The red blood cells are enlarged and have an increased
osmotic fragility and membrane viscosity, whereas their
filterability is reduced.66 Furthermore, the oxygen affinity
of red blood cells may be decreased owing to a reduced
concentration of inorganic phosphorus, glycosylation of
the 2,3-diphosphoglycerate binding site, or pre-existing,
vasculopathy associated with diabetes mellitus.68
These abnormalities contribute to oxidative stress in the
red blood cells and might modulate their flexibility, which
makes them prone to being trapped and sequestered in
the reticulo-endothelial system.9 Furthermore, diabetes
mellitus has been associated with impaired red-blood-cell
deformability, a hemorrheologic perturbation that pro-
motes microvascular complications and anemia. A number
of studies have demonstrated that red blood cells have a role
in the vascular damage associated with diabetic vasculo-
pathy.69 All these factors can contribute to microvascular
disturbances in diabetes mellitus (Figure 2).
Diabetic neuropathy
Diabetic neuropathy is one of the earliest microvascular
complications to occur in patients with diabetes mellitus.
studies in experimental models of the disease have sug-
gested that splanchnic denervation, secondary to auto-
nomic neuropathy, leads to a blunted erythropoietin
response to anemia. A few small, clinical studies have
reported similar findings, which suggest a role of auto-
nomic neuropathy in the initiation of anemia through
alteration of the anemia-sensing mechanisms.34 These
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 reviews
studies demonstrated low levels of circulating erythro-
poietin in patients with type 1 diabetes mellitus who had
neuropathy and normal creatinine levels.
erythropoietin resistance or blunted responses to
endogenous erythropoietin have been reported more
frequently in patients with diabetes mellitus who have
severe autonomic neuropathy than in those diabetic
patients who do not have neuropathy.70 In patients whose
creatinine levels are relatively normal, efferent sympa-
thetic denervation of the kidneys might lead to the loss
of appropriate erythropoietin production, and contribute
to erythropoietin deficiency.34
Correction of anemia
No clear consensus exists on the hemoglobin level that
should trigger investigation into the cause of a patient’s
anemia, but most clinical guidelines suggest a cut-off of
115 g/l in a patient with chronic kidney disease.71–73 As
no clinical data support the benefits of very high or nor-
malized hemoglobin levels on survival, the optimum
level of hemoglobin is still debated.74 The guidelines of
the National Institute for Health and Clinical excellence
(NICe) recommend that hemoglobin levels should be
maintained between 105 g/l and 125 g/l.73
In theory, the correction of anemia should be able to
reverse the effects of the condition; however, reports conflict
on the benefits of anemia correction. early administration of
erythropoietin to predialysis patients with erythropoietin-
deficiency anemia has been reported to alter the progression
of chronic kidney disease and reduce mortality.75 By con-
trast, some major clinical trials that were designed to assess
the effects of anemia correction and determine the optimal
hemoglobin levels, such as CHoIR76 and CReATe,77
reported increased mortality in patients with elevated levels
of hemoglobin, and that the correction of anemia had no
positive effect on the progression of renal disease.
The CHoIR and CReATe studies included patients with
chronic kidney disease, and many of these patients had
diabetes mellitus. Currently, the TReAT study 78 is being
carried out to investigate the effect of anemia correction
(high [130 g/l] and low [90 g/l] target hemoglobin levels)
on mortality and nonfatal cardiovascular events in patients
with type 2 diabetes mellitus. Another multicenter study,
the ACoRD trial,79 is underway and is studying the effects
of the correction of anemia on cardiac structure and func-
tion, and other clinical outcomes in patients with diabetes
who also have anemia and early diabetic nephropathy. The
preliminary results from the ACoRD trial indicate that
anemia correction had beneficial effects in prevention of
left ventricular hypertrophy. At completion, the TReAT and
ACoRD trials might provide us with improved insight into
the benefits of anemia correction in diabetes mellitus.
Correction of anemia with erythropoietin treatment
leads to an increased hematocrit value. However, damaged
blood vessels, which have reduced tensile strength, might
not be able to accommodate the increased numbers of
red blood cells. erythropoietin therapy must be used
cautiously in patients with chronic heart failure and
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ischemic heart disease who are on hemodialysis. very
high hematocrit values might lead to elevated blood pres-
sure and/or vascular thrombosis—known complications
of erythropoietin therapy.80
Conclusions
The erythropoietic stress that results from chronic hyper-
glycemia is a multidimensional condition that affects
patients with diabetes mellitus in early stage of the disease
and has an important role in the development of vasculo-
pathy. erythropoietic stress might also promote a hypoxic
milieu and oxidative stress in the kidneys, which hampers
nutritional support, impairs anti-stress mechanisms,
contributes to sympathetic denervation of the kidneys, and
thus precipitates anemia early in the course of the disease.
Factors that promote erythropoietic stress in patients with
diabetes mellitus include chronic hyperglycemia, increased
production of advanced glycation end products, elevated
levels of free radicals, increased oxidative stress, reduced
nitric oxide production, decreased stabilization of HIF-1,
enhanced endothelial dysfunction, and abnormal erythro-
cyte morphology and function. Chronic inflammation,
abnormal hematinic absorption and certain medications
might worsen erythropoietic stress.
erythropoietic stress coupled with chronic hyperglycemia
might have an important role in the obliteration of peritu-
bular capillaries. such stress might also hamper nutrition
of the tubular interstitium, promote tubular hypoxia and
early tubular damage, and result in tubular dysfunction and/
or apoptosis of tubular cells. surviving tubular cells might
have to work very hard to produce enough erythropoietin
to maintain adequate levels of hemoglobin. However, the
increased workload in presence of chronic hypoxia might
prove counterproductive in the long term, and result in
further loss of tubular cells, which thus creates a vicious cycle
that maintains erythropoietin deficiency and anemia.
Diabetic vasculopathy and endothelial dysfunction
secondary to erythropoietic stress can modulate the
vascular system and, in the absence of adequate repair
processes, might impair the tone and flexibility of blood
vessels. By the time a patient with diabetes mellitus devel-
ops erythropoietin-deficiency anemia, the blood vessels
might be severely damaged and have poor tone and
reduced flexibility.
without clear guidelines on how to manage anemia,
a reasonable aim for clinicians is to maintain levels of
hemoglobin between 105 g/l and 125 g/l, as recommended
by the National Institute for Health and Clinical excel-
lence. Patients with diabetes mellitus should be routinely
monitored for anemia, along with other diabetes-related
complications.
Review criteria
we searched PubMed, Google and scopus for articles
published between 1977 and 2007 that contained the
terms “anemia”, “diabetes,” “diabetic vasculopathy”,
“oxidative stress”, “hypoxia”, “tubular dysfunction”,
“erythropoietin” and “erythropoietin receptors”.
www.nature.com/nrendo

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