This study evaluates the renal anemia refractory to Epo . in hemodialysis patients. all of participants will receive Epo. and identify various factors contributing to etiology of renal anemia in Epo- resistant patients.

Chronic kidney disease (CKD) is considered a public health problem worldwide with high incidence and prevalence rates.Anemia is one of the most frequent early complication of CKD. The main cause is erythropoietin (EPO) deficiency due to impaired kidney function However, other causes should be considered when the severity of anemia is inconsistent with the decrease in renal function; when there is evidence of iron deficiency or matching decreases in hemoglobin, leukopenia and/or thrombocytopenia are also found

Inclusion Criteria:

• Patients greater than or equal to 18 years old with CKD on hemodialysis

Exclusion Criteria:

1. - Evidence of infections especial of vascular access .

2. - malnutrition and manifestation of iron, B12, folate and protein deficiency .

3. - any underling cause as;

   • Hematologic malignances -Hemolytic anemia -
   • Aplastic anemia (infection and/or bleeding with anemia)
   • Solid tumors
   • Bleeding (skin ,mucosal ,orificial)
   • Evidence of mineral bone disease (CKD-MBD)
   • Others

1. The investigators choose 50 uraemic patients on hemodialysis randomly and receiving Epo.among those admitted to nephrology ward and out Patient clinic of the department of internal medicine of Assiut University Hospital.
2. Follow up of patients for 6 months with CBC every month.
3. Searching for number of patients among this 50 who have failure to correct the anemia with Epo. (100IU /Kg / week- SC ) For target HB 11 gm.
4. Effect of bleeding, infection and malnutrition.
5. Scaring for the possible underling cause of anemia refractory to Epo. Clinically, laboratory at the end of study period.