KDIGO Recommends Regular Anemia Screening, Targeted Iron Therapy in CKD
USA: The Kidney Disease: Improving Global Outcomes (KDIGO) has issued updated clinical practice guidance for the management of anemia in chronic kidney disease (CKD), more than a decade after its previous guideline. The 2026 update provides recommendations covering anemia screening, iron deficiency, iron supplementation, erythropoiesis-stimulating agents (ESAs), and newer therapies for anemia associated with CKD.
Published in Kidney International in January 2026, the guideline combines recommendations supported by systematic reviews with additional “practice points” based on expert opinion. However, the guideline authors noted that much of the available evidence remains limited, with several recommendations supported by low or very-low certainty evidence.
The updated guidance emphasizes regular laboratory assessment to identify anemia and iron deficiency and encourages clinicians to individualize treatment according to dialysis status, symptoms, risks, and treatment response.
Key Recommendations:
- Screen regularly for anemia: All patients with CKD should undergo assessment with a complete blood count, reticulocyte count, ferritin, and transferrin saturation (TSAT). Screening should occur at least annually in stage 3 CKD, twice yearly in stage 4, and every 3 months in stage 5 CKD.
- Maintain established anemia thresholds: Anemia continues to be defined as hemoglobin below 12 g/dL in women and below 13 g/dL in men, with age-specific thresholds applying to children younger than 15 years.
- Investigate possible blood loss: When ferritin is below 45 ng/mL or microcytic anemia is present, clinicians should consider evaluating the patient for potential sources of blood loss.
- Initiate iron in selected patients receiving hemodialysis: For patients on hemodialysis, iron therapy should be considered when ferritin is ≤500 ng/mL and TSAT is ≤30%. Intravenous iron is preferred, although this recommendation is based on very-low-certainty evidence.
- Use specific iron thresholds in patients not receiving dialysis: Iron therapy can be considered when ferritin is below 100 ng/mL with TSAT below 40%, or when ferritin is 100–300 ng/mL with TSAT below 25%.
- Monitor iron treatment: CBC, ferritin, and TSAT should generally be monitored every 1–3 months in patients receiving hemodialysis and approximately every 3 months in those not receiving dialysis.
- Pause iron during systemic infection: Temporary discontinuation of iron therapy should be considered when patients develop systemic infections.
- Consider ESAs during dialysis: ESAs may be considered in patients receiving hemodialysis or peritoneal dialysis when hemoglobin falls to approximately 9–10 g/dL.
- Prefer ESAs over HIF-PH inhibitors: ESAs are favored over newer hypoxia-inducible factor–prolyl hydroxylase inhibitors, although the certainty of evidence supporting this recommendation is very low.
- Individualize treatment in nondialysis CKD: In patients who are not receiving dialysis, decisions regarding anemia medications should consider symptoms and the balance between potential benefits and harms.
- Avoid excessive hemoglobin correction: When medications are used, hemoglobin should be maintained below 11.5 g/dL because higher levels may increase the risk of stroke.
- Reassess ESA use during high-risk hospitalizations: Temporary interruption of ESA therapy should be considered when thromboembolic risk is elevated, including during an acute stroke.
The updated guideline provides a framework for managing a common complication of CKD, but its recommendations should not be applied without clinical judgment. Many recommendations are supported by expert opinion or low-certainty evidence, highlighting the need to consider individual patient characteristics, symptoms, treatment risks, and laboratory trends when selecting therapy.
The guidance may nevertheless help clinicians adopt a more systematic approach to anemia screening and iron assessment while balancing the potential benefits of treatment against the risk of unnecessary supplementation or excessive hemoglobin correction.
Reference:
Babitt JL, et al. Executive summary of the KDIGO 2026 Clinical Practice Guideline for the management of anemia in chronic kidney disease (CKD). Kidney Int 2026 Jan; 109:44. DOI: 10.1016/j.kint.2025.06.005.
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