Clinical takeaway
Before starting anemia drugs in CKD, address reversible causes such as iron deficiency, use IV iron as the preferred option in hemodialysis patients, and tailor ESA initiation to symptoms, cardiovascular risk, transplant candidacy, and patient preferences.
The latest guidelines from the Kidney Disease: Improving Global Outcomes (KDIGO) for 2026 have revised the previous recommendations issued in 2012 regarding anemia management for chronic kidney disease (CKD). These updates reflect new evidence concerning iron therapy, erythropoiesis-stimulating agents (ESAs), and hypoxia-inducible factor-prolyl hydroxylase inhibitors (HIF-PHIs). Importantly, the new guidelines emphasize a more personalized approach to treatment decisions instead of adhering to fixed hemoglobin targets or medication thresholds.
A significant change in the guidelines is the stronger recommendation for the proactive use of IV iron in patients undergoing hemodialysis. KDIGO now advises initiating iron therapy when ferritin levels are ≤500 ng/mL and transferrin saturation (TSAT) is ≤30%, with a clear preference for IV iron over oral formulations for this group. This recommendation is primarily based on findings from the PIVOTAL trial, which demonstrated that a proactive strategy using IV iron decreases cardiovascular events, the need for transfusions, and ESA requirements without heightening the risk of infections or other serious adverse events.
For CKD patients who are not on hemodialysis, treatment approaches should be more individualized. Iron therapy should be considered based on ferritin and TSAT levels, but healthcare providers may opt for either oral or IV iron. This decision may depend on factors such as the severity of anemia, patient tolerability, availability, cost, and personal preference.
Another critical update pertains to the use of anemia medications. Once reversible causes of anemia are addressed, KDIGO recommends using ESAs rather than HIF-PHIs as the first-line treatment. While HIF-PHIs can typically increase hemoglobin to levels akin to those achieved with ESAs, the guideline underscores lingering uncertainties regarding their long-term cardiovascular impacts and safety profiles, especially for patients not receiving dialysis.
Furthermore, the guidelines personalize the hemoglobin targets for initiating ESA therapy. In dialysis patients, initiation of ESA treatment is usually recommended when hemoglobin levels drop to 9 to 10 g/dL or lower. In non-dialysis CKD patients, no specific hemoglobin threshold is endorsed; clinicians should weigh symptoms of anemia, advantages of enhanced hemoglobin levels, risks associated with ESA therapy, and the patient’s wish to avoid blood transfusions before making a decision.
Importantly, KDIGO continues to advise against normalizing hemoglobin levels. For adult patients undergoing ESA therapy, the recommendation is to maintain hemoglobin levels below 11.5 g/dL due to evidence indicating that higher targets may elevate the risk of hypertension, thrombotic complications, and cardiovascular incidents.
As highlighted by the authors, this update “underscores the necessity of personalizing treatment to individual patient characteristics and preferences to minimize the risks and maximize the benefits of treatments offered for anemia.”
Disclaimer: This content is intended for informational purposes only and should not be considered medical advice. Always consult a healthcare professional for diagnosis and treatment options tailored to your individual health needs.
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